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Which client assessment should the nurse perform during nasopharyngeal suctioning?

A.

Determine the elasticity of the client’s skin turgor.

B.

Auscultate the bowel sounds in all four quadrants.

C.

Palpate the client’s pedal pulse volume bilaterally.

D.

Observe the client’s skin and mucous membranes.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Determining the elasticity of the client’s skin turgor is not directly related to nasopharyngeal suctioning. Skin turgor assessment is typically used to evaluate hydration status and does not provide information about the respiratory status or the need for suctioning.

 

Choice B rationale

 

Auscultating the bowel sounds in all four quadrants is unrelated to nasopharyngeal suctioning. Bowel sounds assessment is important for gastrointestinal evaluation but does not help in assessing the respiratory status or the effectiveness of suctioning.

 

Choice C rationale

 

Palpating the client’s pedal pulse volume bilaterally is not relevant to nasopharyngeal suctioning. This assessment is used to evaluate peripheral circulation and does not provide information about the respiratory status or the need for suctioning.

 

Choice D rationale

 

Observing the client’s skin and mucous membranes is crucial during nasopharyngeal suctioning. This assessment helps determine the client’s oxygenation status and the presence of cyanosis, which can indicate hypoxia. It also helps in identifying any trauma or irritation caused by the suctioning procedure.
 


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View Related questions

Correct Answer is C

Explanation

Choice A rationale

Tilting the pelvis forwards and backwards exercises the pelvic joints, not the hinge joints.

Choice B rationale

Turning the head to the right and left exercises the neck joints, not the hinge joints.

Choice C rationale

Bending the arm by flexing the ulnar to the humerus exercises the hinge joints, such as the elbow, which is a hinge joint.

Choice D rationale

Extending the arm at the side and rotating in circles exercises the shoulder joint, which is a ball-and-socket joint, not a hinge joint.

Correct Answer is C

Explanation

Choice A rationale

Asking the client if they understand after each instruction may not be effective if the client is not comfortable expressing confusion or misunderstanding. It does not allow for direct observation of the client’s ability to perform the necessary tasks.

Choice B rationale

Having an interpreter repeat the wound care instructions may be helpful, but it still does not allow for direct observation of the client’s ability to perform the necessary tasks.

Choice C rationale

Having the client demonstrate prescribed wound care is the best way to evaluate the client’s understanding of self-care at home. This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.

Choice D rationale

Providing written instructions in the client’s native language may be helpful, but it does not allow the nurse to directly evaluate the client’s understanding.

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