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 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.
Correct Answer is D
Explanation
Choice A rationale
Wearing gloves to dispose of the needle and syringe is a good practice to prevent needlestick injuries and contamination. However, it does not directly indicate an understanding of standard precautions, which emphasize hand hygiene as a primary measure.
Choice B rationale
Removing the needle before discarding used syringes is not recommended as it increases the risk of needlestick injuries. Standard precautions emphasize the safe disposal of sharps in puncture-resistant containers without manipulating the needle.
Choice C rationale
Donning a face mask before administering medication is not a standard precaution for handling syringes and needles. Standard precautions focus more on hand hygiene and the use of gloves when there is a risk of exposure to blood or body fluids.
Choice D rationale
Washing hands before handling the needle and syringe is a fundamental aspect of standard precautions. Hand hygiene is the most effective way to prevent the transmission of infections and is a clear indication of understanding standard precautions.