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. Provide a numeric pain scale:

While a numeric pain scale can help quantify the intensity of pain, it does not directly assess the quality or characteristics of the pain, which is important for identifying potential causes and selecting appropriate interventions.

B. Observe body language and movement:

Observing body language and movement can provide valuable information about the client's pain experience, but it primarily assesses the behavior associated with pain rather than the quality or characteristics of the pain itself.

C. Ask the client to describe the pain:

This approach allows the client to provide subjective information about the pain, including its quality, location, intensity, duration, and aggravating or alleviating factors. Asking the client to describe the pain helps the nurse gain insight into its characteristics, which can aid in identifying the underlying cause and determining appropriate interventions.

D. Identify effective pain relief measures:

Identifying effective pain relief measures is important for managing the client's pain, but it does not directly assess the quality or characteristics of the pain. Before implementing pain relief measures, it's essential to understand the nature of the pain through client self-report or other assessment methods.

A. Capillary refill of 2 seconds in the lower right foot. B. Basilar lung sounds that are diminished in the left lung. C. Contraction of the left pupil when light shines in the right eye. D. Active bowel sounds in the lower right quadrant.

Correct Answer is B

Explanation

A. Capillary refill of 2 seconds in the lower right foot:

Capillary refill of 2 seconds in the lower right foot is within normal limits and does not require documentation in a chart-by-exception system, as it is considered an expected finding.

B. Basilar lung sounds that are diminished in the left lung:

Diminished basilar lung sounds in the left lung may indicate a respiratory issue and would be considered a significant finding warranting documentation in a chart-by-exception system.

C. Contraction of the left pupil when light shines in the right eye:

Contraction of the left pupil when light shines in the right eye is an abnormal finding (consensual response), which should be documented in a chart-by-exception system.

D. Active bowel sounds in the lower right quadrant:

Active bowel sounds in the lower right quadrant are within normal limits and do not require documentation in a chart-by-exception system, as they are considered expected findings.

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Which client assessment should the nurse perform during nasopharyngeal suctioning?

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