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 A

Explanation

A. A well approximated incision site:

A properly healing surgical incision typically appears well approximated, meaning the wound edges are closely aligned and held together with sutures or staples. This indicates that the wound is healing as expected and that the risk of infection and complications is minimized.

B. Erythema and serosanguineous exudate:

Erythema (redness) and serosanguineous exudate (pinkish fluid composed of serum and blood) can be normal findings in the early stages of wound healing, but they may also indicate inflammation or infection if they persist or worsen over time.

C. Eschar and slough in the wound:

Eschar (dead tissue) and slough (yellow or white necrotic tissue) are signs of tissue necrosis or delayed wound healing. They indicate that the wound is not healing properly and may require intervention such as debridement to remove dead tissue and promote healing.

D. Beefy red granulation tissue:

Beefy red granulation tissue is a sign of the proliferative phase of wound healing and indicates that the wound is healing from the bottom up. While granulation tissue is a positive sign of healing, it typically appears later in the healing process rather than one week post-surgery.

A. Clamping the urinary catheter prior to the collection. B. Recording the output on the flowsheet in the client's room. C. Transporting the urine specimen to the laboratory. D. Using the syringe to remove the specimen from the catheter.

Correct Answer is D

Explanation

A. Clamping the urinary catheter prior to the collection:

This step involves temporarily stopping the flow of urine through the catheter. Whether gloves are needed for this step depends on the specific protocol and the potential risk of exposure to bodily fluids. If there's a possibility of urine leakage or splashing during the clamping process, gloves may be necessary to protect against contact with the urine.

B. Recording the output on the flowsheet in the client's room:

This step involves documenting the urine output on a flowsheet or chart. It typically does not require direct contact with bodily fluids, as the nurse is handling paperwork rather than the urine itself. Therefore, gloves are usually not necessary for this task.

C. Transporting the urine specimen to the laboratory:

Once the urine specimen has been collected and properly sealed in a biohazard bag, the nurse transports it to the laboratory for analysis. As long as the specimen is securely packaged, there is no need for gloves during transportation unless there is a risk of spillage or leakage. However, if there is a possibility of contact with bodily fluids due to leakage, gloves should be worn to protect against exposure.

D. Using the syringe to remove the specimen from the catheter:

This step involves using a sterile syringe to withdraw the urine from the catheter for collection. Since it involves direct contact with bodily fluids (i.e., urine), gloves are necessary to protect against potential exposure to pathogens. Wearing gloves during this step helps maintain proper infection control practices and minimizes the risk of contamination.

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Which client assessment should the nurse perform during nasopharyngeal suctioning?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client one week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

Correct Answer is A

Explanation

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

Correct Answer is D

Explanation

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