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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 A

Explanation

Choice A rationale

Verifying the placement of the pulse oximeter is the first step to ensure the accuracy of the oxygen saturation reading. An incorrect placement can lead to inaccurate readings, and addressing this issue can help determine if further interventions are needed.

Choice B rationale

Increasing the oxygen to 3 L/minute may be necessary if the oxygen saturation remains low after verifying the pulse oximeter placement. However, this should be done after ensuring the accuracy of the initial reading.

Choice C rationale

Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia. The patient’s oxygen saturation is low, but not critically low.

Choice D rationale

Removing the nasal cannula is not appropriate as it would further decrease the oxygen supply to the patient. The goal is to improve oxygenation, not reduce it.

Correct Answer is B

Explanation

Choice A rationale

Whether the popsicles contain pulp or fruit is not relevant to the clear liquid diet, which focuses on the clarity and digestibility of the liquids.

Choice B rationale

The color and flavor of gelatin used are important because certain colors, especially red or purple, can interfere with medical tests and are often avoided in clear liquid diets.

Choice C rationale

If the popsicles are completely frozen is not relevant to the dietary restrictions. The focus should be on the ingredients and their suitability for a clear liquid diet.

Choice D rationale

The number of popsicles available does not impact their suitability for the child’s diet. The nurse should focus on the content and appropriateness of the popsicles.

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