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.)

Don sterile gloves.

Turn on the suction and set the pressure.

Insert the catheter during the client's inspiration.

Apply suction while rotating the catheter.

Rinse the catheter to remove secretions.

Answer and Explanation

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

B.   The nurse first prepares the equipment and ensures the suction pressure is set appropriately.
A.   Sterile gloves are then applied to maintain sterile technique during airway suctioning.
C.   The catheter should be inserted during the client’s inspiration to minimize discomfort and maximize
effectiveness.
D.   Suction should be applied while rotating the catheter to prevent tissue damage and to clear secretions effectively.
E.   After suctioning, the catheter should be rinsed to remove any remaining secretions.

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Correct Answer is B

Explanation

A. While adequate fluid intake is important, 1.5 L per day might not be sufficient for a client with chronic pain and opioid use. The client should aim for a higher intake, as recommended by healthcare providers.
B. Increasing physical activity helps promote bowel motility, reducing the risk of constipation. Regular exercise can help counteract opioid-induced constipation.
C. Mineral oil should not be recommended due to its risk of aspiration and interference with vitamin absorption.
D. Insoluble fiber is necessary to help with bowel movements and should be increased, not decreased, to help prevent constipation.

A. Prepare the client for an MRI of the brain. B. Insert an indwelling urinary catheter for the client. C. Determine the client's Glasgow Coma Scale score. D. Administer mannitol IV bolus to the client.

Correct Answer is C

Explanation

A. Preparing the client for an MRI is not the first step; assessment of neurological status is the priority.
B. Inserting an indwelling urinary catheter is unnecessary unless indicated after further assessment.
C. Determining the Glasgow Coma Scale score is the most important initial step to assess the client's neurological status and guide further interventions.
D. Administering mannitol is appropriate for increased intracranial pressure but should only be done after assessing the client's neurological condition.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

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.)

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