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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Blood culture is essential to identify any potential infection that the patient may have, which is a common complication after trauma.
B . Prothrombin time is crucial for assessing the blood's clotting ability, especially since the patient has a suspected fracture and could be at risk of bleeding.
C . Hemoglobin and hematocrit are fundamental tests to evaluate for anemia or blood loss, which is particularly relevant given the patient's fall and the possibility of internal injuries. D . Type and screen is necessary in case the patient requires a blood transfusion due to the injuries sustained from the fall.
E . Albumin is not typically a priority in acute trauma settings and would not necessarily be expected as an immediate test.
F . Lipid panel is not relevant in the acute management of trauma and is not typically ordered in the emergency setting
Correct Answer is C
Explanation
A. Cover client with cooling blanket.
This could help manage the fever but is not the highest priority in the context of acute adrenal crisis.
B. Obtain an analgesic prescription.
Pain management is important, but it is not the immediate priority in a life-threatening adrenal crisis.
C. Infuse an intravenous fluid bolus.
This is the correct answer because the client is experiencing hypotension (low blood pressure), which is critical in an acute adrenal crisis. IV fluids are essential to restore blood pressure and perfusion.
D. Administer PRN oral antipyretic.
Managing the fever is important, but not the first priority. The client’s hemodynamic instability needs to be addressed immediately.
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