Which client assessment should the nurse perform during nasopharyngeal suctioning?

Auscultate the bowel sounds in all four quadrants.

Palpate the client's pedal pulse volume bilaterally.

Determine the elasticity of the client's skin turgor.

Observe the client's skin and mucous membranes.

Answer and Explanation

The Correct Answer is D

A. Auscultate the bowel sounds in all four quadrants:

Auscultating bowel sounds is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating gastrointestinal function and is not a priority during airway management procedures.

B. Palpate the client's pedal pulse volume bilaterally:

Palpating pedal pulse volume is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating peripheral vascular perfusion and is not a priority during airway management procedures.

C. Determine the elasticity of the client's skin turgor:

Assessing skin turgor elasticity is not directly relevant to nasopharyngeal suctioning. This assessment is typically performed to evaluate hydration status and is not a priority during airway management procedures.

D. Observe the client's skin and mucous membranes:

This is the most appropriate assessment during nasopharyngeal suctioning. Observing the client's skin and mucous membranes helps monitor for signs of respiratory distress, such as cyanosis, pallor, or increased respiratory effort. It also allows the nurse to assess the effectiveness of airway clearance and potential complications related to the procedure.

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Correct Answer is C

Explanation

A. Obtaining clarification from a client's healthcare power-of-attorney:

While clear communication is important in this scenario, SBAR may not be necessary as the nurse is seeking information rather than providing a detailed report or recommendation.

B. Completing discharge teaching to a client and family members:

SBAR may not be the most suitable format for discharge teaching, as it is primarily used for communication between healthcare providers regarding a patient's condition and care plan. Discharge teaching typically involves providing comprehensive instructions and information in a manner tailored to the needs of the client and family members.

C. Reporting a change in a client's condition to the healthcare provider:

This is the most appropriate scenario for using the SBAR format. When communicating a change in a client's condition to the healthcare provider, the SBAR framework allows the nurse to provide a concise summary of the situation, relevant background information, assessment findings, and recommendations for further action.

D. Offering therapeutic support and comfort to a grieving family:

SBAR communication is not suitable for offering therapeutic support and comfort to a grieving family. This interaction requires empathy, active listening, and emotional support rather than a structured communication format like SBAR.

A. Inject In abdominal area at least 2 in (5.1 cm) from the umbilicus. B. Rotate injections between the abdomen and gluteal areas. C. Expel the air in the prefilled syringe prior to Injection. D. Massage the injection site to increase absorption.

Correct Answer is A

Explanation

A. Inject in abdominal area at least 2 in (5.1 cm) from the umbilicus:

This instruction is accurate and appropriate for the administration of low molecular weight heparin subcutaneously. Injecting into the abdominal area at least 2 inches (5.1 cm) away from the umbilicus is a commonly recommended site for subcutaneous injections due to the availability of subcutaneous tissue and the reduced risk of injury to underlying structures.

B. Rotate injections between the abdomen and gluteal areas:

While rotation of injection sites is important to prevent tissue damage and lipodystrophy, for subcutaneous injections of low molecular weight heparin, the abdomen is typically the preferred site due to better absorption and reduced risk of complications. Therefore, rotating between the abdomen and gluteal areas may not be necessary or recommended for this specific medication.

C. Expel the air in the prefilled syringe prior to injection:

Expelling air from the prefilled syringe is a standard practice to ensure accurate dosing and prevent air embolism, but it is not specific to the administration of low molecular weight heparin. This instruction should be included in general injection technique education but is not specific to the administration of this medication.

D. Massage the injection site to increase absorption:

Massaging the injection site after administration of low molecular weight heparin is not recommended, as it can increase the risk of bleeding or hematoma formation at the injection site. Massaging the site is generally contraindicated for anticoagulant injections to avoid disrupting the clotting process.

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Which client assessment should the nurse perform during nasopharyngeal suctioning?

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Correct Answer is C

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Correct Answer is A

Explanation

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