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 A
Explanation
Choice A rationale
The SBAR (Situation, Background, Assessment, Recommendation) format is specifically designed for critical communication, particularly when reporting a change in a client’s condition to the healthcare provider. This structured communication tool ensures that essential information is conveyed clearly and concisely, reducing the risk of miscommunication and enhancing patient safety.
Choice B rationale
Completing discharge teaching to a client and family members typically involves providing comprehensive instructions and education, which may not fit the concise and focused nature of the SBAR format. Discharge teaching requires a more detailed and interactive approach to ensure understanding and compliance.
Choice C rationale
Obtaining clarification from a client’s healthcare power-of-attorney involves a more conversational and detailed exchange of information, which may not align with the structured and concise nature of the SBAR format. This interaction often requires a thorough discussion to ensure all aspects are understood.
Choice D rationale
Offering therapeutic support and comfort to a grieving family is a sensitive and empathetic interaction that requires a compassionate and patient-centered approach. The SBAR format is not suitable for this type of communication, as it is designed for conveying critical information quickly and efficiently.
Correct Answer is A
Explanation
Choice A rationale
Using the syringe to remove the specimen from the catheter requires the nurse to wear gloves to maintain sterility and prevent contamination. Gloves protect both the nurse and the patient from potential pathogens present in the urine.
Choice B rationale
Transporting the urine specimen to the laboratory does not require gloves as the specimen is already secured in a biohazard bag, minimizing the risk of contamination.
Choice C rationale
Recording the output on the flowsheet in the client’s room does not involve direct contact with the urine specimen, so gloves are not necessary.
Choice D rationale
Clamping the urinary catheter prior to the collection does not require gloves as it is a preliminary step that does not involve direct contact with the urine.