which of the following indicates a hazard for a client on oxygen therapy

NCLEX-PN

Nclex Exam Cram Practice Questions

1. Which of the following indicates a hazard for a client on oxygen therapy?

A. A 'No Smoking' sign is on the door.
B. The client is wearing a synthetic gown.
C. Electrical equipment is grounded.
D. Matches are removed.

Correct answer: B

Rationale: The correct answer is that the client is wearing a synthetic gown. A synthetic gown might generate sparks of static electricity, which can be a fire hazard, especially in the presence of oxygen. Clients on oxygen therapy should wear cotton gowns to minimize the risk of fire. The other options are not hazards for a client on oxygen therapy: having a 'No Smoking' sign on the door promotes safety by preventing smoking, ensuring electrical equipment is grounded reduces the risk of electrical hazards, and removing matches decreases the risk of fire hazards.

2. Which of the following statements describes the purpose of client restraint?

A. Restraints are a nursing measure used to maintain client control.
B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.
C. Restraints are a therapeutic measure designed to positively reinforce client behavior.
D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.

Correct answer: B

Rationale: The correct answer is B. Restraints are used as an emergency intervention when all other options to protect a client from imminent danger have been exhausted. Restraints should only be used as a last resort to ensure the safety of the client and others. Choices A, C, and D are incorrect because restraints are not used to maintain control, reinforce behavior, or are exclusively taken under direct physician supervision. It is crucial to remember that restraint use should always be based on careful assessment, documentation, and adherence to legal and ethical guidelines.

3. When making an occupied bed, what is important for the nurse to do?

A. keep the bed in the low position.
B. use a bath blanket or top sheet for warmth and privacy
C. constantly keep side rails raised on both sides.
D. move back and forth from one side to the other when adjusting the linens.

Correct answer: B

Rationale: When making an occupied bed, using a bath blanket or top sheet is important as it keeps the client warm and provides privacy, ensuring their comfort and dignity. Keeping the bed in the low position is crucial for the safety of the client, preventing falls and injuries. Constantly keeping side rails raised on both sides is unnecessary and may restrict the client's movement unnecessarily. Moving back and forth from one side to the other when adjusting the linens is inefficient and disrupts the workflow; it is more effective to work systematically from one side to the other to ensure proper bed-making.

4. During shift change, a nurse is giving report to the oncoming LPN. Which of these is an inappropriate way to give shift report?

A. The nurse gives report to the oncoming LPN, checking a wound vac and dressing together.
B. The nurse reports in SBAR format, noting that the client was noncompliant with their diet during the shift.
C. The nurse reports in the hallway, in SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.
D. The nurse reports at bedside with the oncoming LPN and discusses the client's concerns after the chart has been reviewed.

Correct answer: C

Rationale: The correct answer is 'The nurse reports in the hallway, in SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.' This choice is inappropriate because shift report should be given at the bedside, in SBAR format, and in an objective way. It is important to maintain professionalism and focus on the client's condition and care needs, rather than personal opinions or subjective comments. Reporting in the hallway may compromise patient privacy and confidentiality. Choices A, B, and D demonstrate appropriate ways of giving shift report by focusing on relevant information, using SBAR format, and discussing client concerns after reviewing the chart, which promotes effective communication and continuity of care.

5. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:

A. Increase maternal fluids.
B. Administer oxygen.
C. Decrease maternal fluids.
D. Turn the mother.

Correct answer: C

Rationale: When fetal heart monitoring indicates fetal distress, interventions are aimed at improving oxygenation to the fetus. Increasing maternal fluids helps improve placental perfusion and oxygen delivery to the fetus. Administering oxygen also aids in increasing oxygen supply to the fetus. Turning the mother can help relieve pressure on the vena cava, optimizing blood flow to the placenta. Therefore, decreasing maternal fluids would not be performed as it can further compromise placental perfusion and fetal oxygenation, making it the exception. Decreasing maternal fluids could potentially exacerbate fetal distress by reducing oxygen delivery and nutrient supply to the fetus, which is contrary to the goal of managing fetal distress.