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174. A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Rinse the catheter to remove secretions.

Don sterile gloves.

Apply suction while rotating the catheter.

Insert the catheter during the client's inspiration.

Turn on the suction and set the pressure.

Answer and Explanation

The Correct Answer is E, B, D,C,A

2. E. Turn on the suction and set the pressure.

1. B. Don sterile gloves.

3. D. Insert the catheter during the client's inspiration.

4. C. Apply suction while rotating the catheter.

5. A. Rinse the catheter to remove secretions.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

Anticipated actions for the client include:
- A. Administer nifedipine.

- B. Assess blood pressure every 15 minutes.

- D. Assess for urinary retention.
Contraindicated actions for the client include:

- C. Perform suctioning (since there is no indication or information suggesting the need for suctioning).
- E. Place client in supine position (as it might worsen the symptoms).

- F. Withhold pain medication for headache until other manifestations resolve (it's important to address the headache promptly, especially if acetaminophen is prescribed for pain relief).

A. Document the client's level of understanding about potential adverse effects. B. Teach the client how to insert the diaphragm. C. Determine the client's knowledge about diaphragm use. D. Supervise return demonstration of diaphragm use.

Correct Answer is C

Explanation

A. Incorrect. Documenting the client's understanding of adverse effects is important, but ensuring the client's knowledge about diaphragm use is the first step.

B. Incorrect. Teaching the client how to insert the diaphragm can be an important step, but first, it's essential to assess the client's existing knowledge.

C. Correct. Before proceeding with teaching or other actions, it's important to determine the client's baseline understanding of diaphragm use.

D. Incorrect. Supervising the return demonstration is important but should come after the client's knowledge level is assessed.

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174. A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

A nurse is caring for a female client who requests a contraceptive diaphragm. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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