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174. A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Rinse the catheter to remove secretions.

Don sterile gloves.

Apply suction while rotating the catheter.

Insert the catheter during the client's inspiration.

Turn on the suction and set the pressure.

Answer and Explanation

The Correct Answer is E, B, D,C,A

2. E. Turn on the suction and set the pressure.

1. B. Don sterile gloves.

3. D. Insert the catheter during the client's inspiration.

4. C. Apply suction while rotating the catheter.

5. A. Rinse the catheter to remove secretions.

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Correct Answer is C

Explanation

A. Incorrect. Urination is not directly related to the evaluation of the effectiveness of a paracentesis procedure.
B. Incorrect. Checking serum albumin levels may be important in managing ascites, but it is not a direct measure of the immediate effectiveness of the paracentesis.
C. Correct. Monitoring the client's weight is a common way to assess the effectiveness of a paracentesis, as the procedure aims to remove excess abdominal fluid (ascites), which can lead to a reduction in body weight.
D. Incorrect. Examining for leakage at the site of the procedure is important for safety but does not directly reflect the effectiveness of the paracentesis.

A. "I can start the medication 30 minutes earlier." B. "I can infuse the medication at a faster rate." C. "I have up to 2 hours after the usual scheduled time to give you this medication." D. "I can adjust the time and schedule for when it's convenient for you."

Correct Answer is A

Explanation

A. Administering the medication 30 minutes earlier may not be appropriate without specific orders from the provider.
B. Infusing the medication at a faster rate is not a solution for adjusting the timing of the dose.
C. Administering the medication up to 2 hours after the usual schedule time is incorrect because it could lead to subtherapeutic levels and reduced effectiveness.

D. Adjusting the medication schedule solely for the convenience of the client without consulting the provider is not recommended.

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174. A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

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A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate the effectiveness of the procedure?

Correct Answer is C

Explanation

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Correct Answer is A

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