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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I am sorry to disturb you at a difficult time. This can wait until later."
This response acknowledges the client's distress but does not actively engage with the client's emotions or offer support. It also suggests postponing the assessment, which may not be necessary if the client is willing to discuss their feelings.
B. “While touching the client's forearm, asks, 'Would you like to talk about it?'"
This response demonstrates empathy and offers the client an opportunity to express their feelings if they wish to do so. By gently touching the client's forearm and asking if they would like to talk, the nurse conveys support and openness to the client's emotional needs.
C. "This is a bad time. I can see you are upset. I can come back later."
While this response acknowledges the client's emotions and offers to return later, it may not be the most helpful approach. It assumes that the client does not want to engage in conversation at that moment without giving them the opportunity to express their preferences.
D. “Gives the client a hug and says, 'It is okay to cry when you are sad.'"
While offering physical comfort like a hug can be appropriate in some situations, it's important to respect the client's personal boundaries and preferences, especially if they are in distress. Additionally, some clients may not feel comfortable with physical touch from healthcare providers. This response also assumes the client's emotions without directly addressing their needs or offering them an opportunity to express themselves verbally.
Correct Answer is C
Explanation
A. Speak loudly and face the client:
While it's important for the nurse to speak clearly and ensure the client can see their face, speaking loudly may be perceived as patronizing or disrespectful. Many older adults may have normal hearing but prefer clear and normal volume speech.
B. Provide a very well-lit meeting space:
Ensuring adequate lighting is important for facilitating communication, especially for older adults who may have visual impairments. However, it is not as crucial as using understandable language.
C. Use everyday language when explaining issues:
This is the most important action. Using everyday language, free of medical jargon, ensures that the information is easily understood by older adult clients. Complex medical terms and terminology may be confusing or overwhelming for them, so using plain language enhances comprehension and promotes effective learning.
D. Underline key words on the written information:
This can be a helpful strategy for emphasizing important points in written materials, but it is not as critical as using everyday language when explaining concepts orally. Additionally, not all older adults may benefit from written information, as some may have visual impairments or difficulties reading. Therefore, oral communication in understandable language is paramount.
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