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 D

Explanation

A. How many popsicles are available.

This information might be helpful for logistical purposes or to assess how much the child has consumed, but it's not directly relevant to ensuring the appropriateness of the popsicles for a clear liquid diet.

B. If the popsicles are completely frozen.

While it's important that popsicles are properly frozen to avoid potential choking hazards, this does not address whether the popsicles meet the dietary requirement of clear liquids.

C. The color and flavor of gelatin used.

While this might be of interest, the key concern is whether the popsicles contain any non-clear components like fruit or pulp.

D. Whether they contain pulp or fruit.

For a child who needs clear liquids, it is important to ensure that the popsicles do not contain any solids like fruit or pulp. Clear liquids are meant to be easily digestible and not irritate the stomach further. Popsicles with pulp or fruit can be too heavy and might not be appropriate in this situation.

A. Begin the collection the next day. B. Start collecting the specimen with the next void. C. Observe the sample for sediment. D. Empty the sample into the 24 hour container.

Correct Answer is B

Explanation

A. Begin the collection the next day:

This option would delay the start of the 24-hour urine collection unnecessarily. Since the client has already begun voiding, it's appropriate to start the collection process with the next void.

B. Start collecting the specimen with the next void:

Since the client has already provided a urine sample, the nurse should discard this initial void and begin the 24-hour collection process with the next void. This ensures that the entire 24-hour period is captured for accurate measurement of creatinine clearance.

C. Observe the sample for sediment:

While observing the sample for sediment may be part of the assessment process, it is not the priority in this situation. The focus should be on initiating the 24-hour urine collection process correctly.

D. Empty the sample into the 24-hour container:

The initial void should not be emptied into the 24-hour container, as this would inaccurately include urine that was not collected over the entire 24-hour period. It's important to start the collection process fresh with the next void to ensure accurate results for creatinine clearance measurement.

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Which client assessment should the nurse perform during nasopharyngeal suctioning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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