The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

Apply a water-soluble lubricant to the catheter.

Wear protective goggles while performing the procedure.

Instill 3 mL of normal saline before suctioning.

Instruct the client to cough as the suction tip is removed.

Answer and Explanation

The Correct Answer is B

A.   Apply a water-soluble lubricant to the catheter. Lubricating the suction catheter can facilitate insertion, but applying a lubricant is not the primary action needed to address excessive drooling.
Additionally, water-soluble lubricants may not provide adequate protection against potential splashes or droplets.
B.   Wear protective goggles while performing the procedure. Excessive drooling in a client with ALS may increase the risk of exposure to saliva and potential aerosolized droplets during
suctioning. Wearing protective goggles helps prevent exposure to bodily fluids and reduces the risk of infection for the nurse.
C.   Instill 3 mL of normal saline before suctioning. Instilling normal saline before suctioning is not typically indicated for oral suctioning in a client with excessive drooling. This action may increase the risk of aspiration and is unnecessary for managing drooling.
D.   Instruct the client to cough as the suction tip is removed. Instructing the client to cough is not appropriate for oral suctioning. Coughing may increase the production of saliva and exacerbate drooling. Additionally, this action does not address the nurse's safety during the suctioning
procedure.

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Correct Answer is B

Explanation

A: Leaving the client alone could increase the risk of harm to herself or others and does not address the immediate need for safety and boundaries.
B: Clearly stating that undressing is unacceptable sets immediate boundaries, which is essential in managing acute behavioral situations, ensuring the client's dignity, and maintaining a professional environment.
C: Ignoring the behavior does not provide any guidance or boundaries for the client, which could lead to escalation or reinforce the inappropriate behavior.
D: While changing to less anxiety-provoking questions may be helpful, it does not directly address the behavior at hand, which could lead to further inappropriate actions or misunderstandings about acceptable behavior during the assessment.

Correct Answer is ["18"]

Explanation

First, we need to find the concentration of Heparin per milliliter in the current infusion. We can do this by dividing the total number of Heparin units by the total volume of the infusion:

Heparin concentration (units/mL) = Total Heparin units / Total volume (mL) Heparin concentration = 25,000 units / 500 mL

Heparin concentration = 50 units/mL

Now, we know the desired rate of Heparin delivery (900 units/hour) and the concentration of Heparin per milliliter (50 units/mL). We can use this information to calculate the required flow rate in milliliters per hour:

Flow rate (mL/hour) = Desired Heparin rate (units/hour) / Heparin concentration (units/mL)

Flow rate = 900 units/hour / 50 units/mL Flow rate = 18 mL/hour

Therefore, the nurse should set the infusion pump to deliver 18 mL/hour.

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The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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