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 B

Explanation

A. Places food on the unaffected side of the mouth:

This is correct practice for clients at risk for aspiration. Placing food on the unaffected side helps ensure safer swallowing.

B. Raises the head of the bed to 60 degrees:

Clients at risk for aspiration-especially after a CVA (stroke)-should have the head of the bed elevated to at least90 degrees during feeding.60 degrees is insufficient to fully protect the airway and reduce the risk of aspiration.

C. Positions the head with the chin tilted slightly downward:

Positioning the head with the chin tilted slightly downward (chin tuck) helps close off the airway during swallowing, further reducing the risk of aspiration. This is another appropriate technique to minimize the risk of aspiration during feeding.

D. Allows 30 minutes of rest before feeding:

Resting reduces fatigue, which can improve swallowing safety and coordination.

A. After each Instruction, ask If the client understands. B. Have an Interpreter repeat the wound care Instructions. C. Provide written instructions in the client's native language. D. Have the client demonstrate prescribed wound care.

Correct Answer is D

Explanation

A. After each instruction, ask if the client understands:

While checking for understanding after each instruction is important, it may not accurately assess the client's ability to perform wound care independently. Verbal confirmation does not ensure competency in wound care techniques.

B. Have an interpreter repeat the wound care instructions:

Having an interpreter repeat the wound care instructions may help ensure accurate communication, but it does not assess the client's ability to perform the wound care independently.

C. Provide written instructions in the client's native language:

Providing written instructions in the client's native language can be helpful for reference, but it may not effectively assess the client's understanding or ability to perform the wound care.

D. Have the client demonstrate prescribed wound care:

This is the most appropriate method for evaluating the client's understanding of self-care at home. Having the client demonstrate wound care techniques allows the nurse to directly observe the client's competency in performing the necessary tasks. It provides a practical assessment of the client's ability to independently manage wound care post-discharge. If the client is unable to demonstrate the procedure correctly, the nurse can provide additional education and support as needed.

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Which client assessment should the nurse perform during nasopharyngeal suctioning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Correct Answer is B

Explanation

A client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self care at home?

Correct Answer is D

Explanation

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