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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Use a peak flow meter to assess the respiratory status. Assessing the client's respiratory status using a peak flow meter is the most appropriate next action after administering albuterol, a bronchodilator. It helps determine the client's lung function and response to the medication. This information guides further interventions and treatment decisions.
Choice B rationale:
Administer a stat dose of corticosteroids. Administering corticosteroids may be indicated in some cases of respiratory distress or exacerbation of asthma. However, it should not be the immediate next step after albuterol administration. Assessing the client's response to albuterol through lung function testing (peak flow) is essential before deciding on additional medications.
Choice C rationale:
Document the normal finding in the client's health record. Documenting normal findings is important for maintaining accurate medical records, but in this case, it is premature. The nurse should first assess the client's response to albuterol and ensure that the respiratory status is indeed normal before documenting the findings.
Choice D rationale:
Repeat a dose of the client's rescue drug. Administering another dose of the rescue drug (albuterol) without assessing the client's response and lung function would not be the most appropriate action. It is essential to determine whether the initial dose was effective before considering additional doses or alternative treatments.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale:
The nurse should consider the patient's physical abilities and limitations when planning recreational activities because this information is crucial for ensuring the safety and appropriateness of the activities. For example, a patient with limited mobility may benefit from activities that can be done in a seated position, while a patient with greater physical abilities may be able to engage in more active pursuits.
Choice B rationale:
The patient's cognitive abilities and limitations should also be taken into account when planning activities. Some patients may have cognitive impairments that require simpler, more straightforward activities, while others may be able to participate in more complex or intellectually stimulating options. This ensures that the activities are enjoyable and suitable for the individual's cognitive capacity.
Choice C rationale:
Considering the patient's interests and preferences is essential to make the recreational activities meaningful and enjoyable. It is important to involve patients in activities they find interesting and pleasurable, as this can have a positive impact on their emotional and psychological well-being during the rehabilitation process.
Choice E rationale:
The patient's cultural and religious background is an important consideration when planning activities. Some activities may be more or less acceptable to individuals from different cultural or religious backgrounds. It's essential to respect cultural and religious preferences to ensure that the activities do not cause discomfort or offense to the patients.
Choice D rationale:
The patient's age and gender are not the primary factors to consider when selecting appropriate activities for individuals in a rehabilitation and restorative care setting. Age and gender do not necessarily determine a person's interests, physical abilities, or cognitive limitations. Therefore, they are not as relevant as the other factors listed in this context.
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