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?

Instill 3 mL of normal saline before suctioning.

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

Apply a water-soluble lubricant to the catheter.

Wear protective goggles while performing the procedure.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Instill 3 mL of normal saline before suctioning. This choice is not appropriate for suctioning excessive drooling in a client with ALS. Instilling normal saline would introduce additional fluid into the oral cavity, potentially worsening the problem by increasing the amount of secretions. The goal of suctioning is to remove excess saliva and maintain a clear airway.

Choice B rationale:

Instruct the client to cough as the suction tip is removed. Instructing the client to cough during suctioning is not a recommended practice. It may cause discomfort and can lead to an increased risk of aspiration as the client might inhale while coughing during the procedure.

Choice C rationale:

Apply a water-soluble lubricant to the catheter. Applying a water-soluble lubricant to the suction catheter is a common practice to facilitate the passage of the catheter and minimize irritation to the client's oral tissues. While it is a helpful step, it is not the primary action that should be taken to ensure the safety of the procedure.

Choice D rationale:

Wear protective goggles while performing the procedure. This is the correct choice. When suctioning a client's oral cavity, especially when dealing with excessive drooling or secretions, it is essential for the nurse to wear protective goggles. These goggles protect the nurse's eyes from potential exposure to the client's bodily fluids, reducing the risk of infection transmission.

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Correct Answer is A

Explanation

Step 1 is to determine the amount of darbepoetin alfa in each mL of solution. The vial is labeled as “60 mcg/mL”, which means each mL contains 60 mcg of darbepoetin alfa.

Step 2 is to calculate the volume of the solution that contains 40 mcg of darbepoetin alfa. This can be done by dividing the prescribed dosage by the concentration of the solution. So, the volume is 40 mcg ÷ 60 mcg/mL = 0.67 mL.

However, since we need to round to the nearest tenth, the volume becomes 0.7 mL.

So, the correct answer is, after analysing all choices, the nurse should administer 0.7 mL of the darbepoetin alfa solution.

A. "It's okay if you don't want to look or talk about the mastectomy. It will be available when you're ready." B. "Would you like me to call another nurse to be here while I show you the wound?" C. "Part of recovery is accepting your new body image, and you will need to look at your incision." D. "You will feel beter when you see that the incision is not as bad as you may think."

Correct Answer is A

Explanation

When a client refuses to look at their mastectomy incision and refuses to talk about it, the best response by the practical nurse (PN) is to respect the client's autonomy and validate their feelings. Option a) acknowledges the client's discomfort and provides reassurance that it is okay for them to decline looking or talking about the incision at the moment. It also oﬀers support by letting the client know that the incision will be available for examination when they feel ready to do so.

Let's evaluate the other options:

b) "Would you like me to call another nurse to be here while I show you the wound?"
This response assumes that the client needs someone else present to address their refusal to look at the incision. While having another nurse present may be helpful for some clients, it is not the appropriate first response. Respecting the client's autonomy and providing support should be the initial approach.

c) "Part of recovery is accepting your new body image, and you will need to look at your incision."
This response may come across as directive and insensitive. It implies that the client must look at their incision as part of their recovery process, disregarding their feelings and personal choices. It is important to respect the client's autonomy and allow them to navigate their own healing journey at their own pace.

d) "You will feel beter when you see that the incision is not as bad as you may think."
This response invalidates the client's feelings and assumes that their concerns about the incision are unfounded. It is essential to respect the client's emotions and validate their experience rather than dismissing or minimizing their concerns.

In summary, when a client refuses to look at their mastectomy incision and refuses to talk about it, the best response by the practical nurse (PN) is to acknowledge the client's discomfort, respect their autonomy, and provide reassurance that it is okay for them to decline looking or talking about the incision at that moment. The client's readiness to address the incision should be honored, and support should be oﬀered when they are ready.

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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

A client with chronic kidney disease receives a prescription for darbepoetin alfa 40 mcg subcutaneous every 7 days. The darbepoetin alfa vial is labeled, "60 mcg/mL." How many mL should the nurse administer? round to the nearest tenth.

Correct Answer is A

Explanation

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

Correct Answer is A

Explanation

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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?