Which client assessment should the nurse perform during nasopharyngeal suctioning?
Determine the elasticity of the client’s skin turgor.
Auscultate the bowel sounds in all four quadrants.
Palpate the client’s pedal pulse volume bilaterally.
Observe the client’s skin and mucous membranes.
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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Correct Answer is B
Explanation
Choice A rationale
Assessing the strength of deep tendon reflexes is important in evaluating neuromuscular function, but it is not the most critical intervention for a client with hyperkalemia. Hyperkalemia primarily affects cardiac function, so monitoring the heart is crucial.
Choice B rationale
Determining the apical pulse rate and rhythm is the most important intervention for a client with a serum potassium level of 7.5 mEq/L. Hyperkalemia can cause life-threatening cardiac arrhythmias, and monitoring the heart rate and rhythm can help detect early signs of these complications.
Choice C rationale
Observing the color and amount of urine can provide information about kidney function and hydration status, but it is not the most critical intervention for hyperkalemia. The primary concern with hyperkalemia is its effect on the heart.
Choice D rationale
Comparing muscle strength bilaterally can help assess neuromuscular function, but it is not the most critical intervention for hyperkalemia. The focus should be on monitoring cardiac function to prevent life-threatening complications.
Correct Answer is C
Explanation
Choice A rationale
Placing the vial with the remainder of the medication into a locked drawer is not appropriate because it does not ensure proper documentation and accountability for the remaining medication. Controlled substances require strict documentation and disposal procedures.
Choice B rationale
Withdrawing the medication into a syringe and labeling it with the client’s name is not necessary and can lead to errors or contamination. The medication should not be stored for future use in this manner.
Choice C rationale
Asking another nurse to witness the medication being discarded is the correct action. This ensures proper documentation, accountability, and compliance with regulations for the disposal of unused or remaining medications, especially controlled substances.
Choice D rationale
Throwing the vial into the trash in the presence of another nurse is not appropriate. It does not ensure proper documentation, accountability, or safe disposal of the remaining medication. Controlled substances require specific disposal procedures to prevent misuse or diversion.