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 D
Explanation
Choice A rationale
Requesting removal initiated by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation. This approach does not address the need to document the 0900 occurrence.
Choice B rationale
Creating an electronic correction after 1400 notes are officially unlocked implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.
Choice C rationale
Entering the occurrence after the 1400 notes and identifying it as a “late entry” is an option, but it may not provide sufficient clarity regarding the timing of the documentation. Using a “late entry” label could potentially lead to confusion or misinterpretation.
Choice D rationale
Making an electronic addendum following the 1400 documentation is the best approach. An electronic addendum allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact. It ensures accuracy and transparency in the medical record.
Correct Answer is A
Explanation
Choice A rationale
Smoking cessation is the most important lifestyle modification for preventing and managing cardiac disease. Smoking is a major modifiable risk factor that can cause atherosclerosis, hypertension, arrhythmias, thrombosis, and myocardial infarction. Quitting smoking has a more direct effect on improving the function and structure of the blood vessels and heart, significantly reducing the risk of cardiovascular events and mortality.
Choice B rationale
A low-fat diet is a useful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. While it helps in lowering cholesterol levels and reducing inflammation, smoking cessation has a stronger influence on overall cardiovascular health.
Choice C rationale
Stress reduction is a helpful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Although managing stress can improve heart health, smoking cessation has a more immediate and significant impact on reducing cardiovascular risks.
Choice D rationale
Regular exercise is beneficial for preventing and managing cardiac disease, but it is not the most important lifestyle modification. Exercise helps in maintaining a healthy weight, lowering blood pressure, and improving overall cardiovascular health, but smoking cessation has a greater impact on reducing the risk of cardiovascular events.