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 A

Explanation

A. Avoid stimulation of the breasts and wear a tight bra: This is the most appropriate recommendation for a bottle-feeding postpartum client with breast engorgement. Minimizing breast stimulation and wearing a supportive, tight-fitting bra can help reduce milk production and alleviate discomfort.

B. Express a small amount of breast milk by hand: This action may provide temporary relief but can stimulate further milk production, which is not advisable for a client who is bottle-feeding and attempting to suppress lactation.

C. Place warm packs on both breasts: Warmth can promote milk flow and is typically recommended for breastfeeding mothers. For a bottle-feeding client, cold compresses are more appropriate to reduce engorgement.

D. Take a prescribed analgesic and expose breasts to air: While analgesics can help manage discomfort, exposing the breasts to air has no therapeutic benefit for engorgement and may increase discomfort. This is not the best overall recommendation.

A. A Guide in moving the non affected limb to override the sensation being experienced. B. B Reassure that this can be a normal postsurgical sensation. C. C Affirm that a prosthetic with physical therapy will gradually improve the symptoms. D. D Explain that the sensations of tingling and pain are not real.

Correct Answer is B

Explanation

A. Guide in moving the non-affected limb to override the sensation being experienced.
Encouraging movement of the non-affected limb may not effectively address phantom limb pain and could potentially exacerbate discomfort or distress.

B. Reassure that this can be a normal postsurgical sensation.
Phantom limb pain is a common phenomenon after amputation surgeries. Providing reassurance that this sensation is normal can help alleviate anxiety and provide comfort to the adolescent.

C. Affirm that a prosthetic with physical therapy will gradually improve the symptoms.
While a prosthetic limb and physical therapy can help in the long term, they may not immediately address the phantom limb pain experienced in the early postoperative period.

D. Explain that the sensations of tingling and pain are not real.
Invalidating the adolescent's experience of phantom limb pain by suggesting that the sensations are not real may worsen distress and anxiety. It's essential to acknowledge the client's experience and provide supportive care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A postpartum client who is bottle-feeding develops breast engorgement. Which is the best recommendation for the nurse to provide this client?

Correct Answer is A

Explanation

The nurse is providing postoperative care for an adolescent who had an amputation of the left leg for osteosarcoma. The adolescent describes experiencing phantom limb pain. Which non pharmacological intervention should the nurse provide?

Correct Answer is B

Explanation

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