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 C

Explanation

Choice A rationale:

Domestic violence assistance is an important topic, but it falls under secondary and tertiary prevention rather than primary disease prevention, which is the focus of this community outreach program. Primary prevention aims to prevent the disease from occurring in the first place, while domestic violence assistance addresses an existing issue.

Choice B rationale:

Blood pressure screening is valuable for early detection of hypertension, but it also falls under secondary prevention. Primary prevention focuses on preventing the onset of diseases through measures such as immunizations, health education, and lifestyle modifications.

Choice D rationale:

Outreach for support group information is essential for clients with chronic conditions or specific needs. However, it is not primarily related to preventing diseases at the population level, which is the primary goal of this community outreach program. This topic may be more relevant to secondary and tertiary prevention efforts.

A. Procure platelet products from the blood bank. B. Titrate oxygen to the prescribed parameters. C. Monitor an intravenous infusion rate on an established schedule. D. Insert a urinary catheter for an uncomplicated client.

Correct Answer is C

Explanation

Choice A rationale:

Procuring platelet products from the blood bank is a task that should be performed by a licensed nurse, not an unlicensed assistive personnel (UAP). It involves assessing the client's needs, verifying orders, and administering the product, which require nursing judgment and skills.

Choice B rationale:

Titrating oxygen to prescribed parameters is a nursing task that requires clinical judgment, especially if the client's condition changes. UAPs do not have the training or scope of practice to adjust oxygen levels. This task should be assigned to a licensed nurse.

Choice D rationale:

Inserting a urinary catheter, even for an uncomplicated client, is a task that should be performed by a licensed nurse. It involves the potential risk of infection and injury, and it requires sterile technique and assessment of the client's condition. UAPs do not have the training or scope of practice to insert urinary catheters.

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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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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?