A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

A. Correct. A health care surrogate (also known as a health care proxy or agent. is designated by the individual to make medical decisions on their behalf if they are unable to do so. This individual should be someone the client trusts and is aware of the client's preferences.
B. Incorrect. A living will can be changed or updated by the individual at any time if their preferences change. It is important for the client to review and revise their living will as needed.
C. Incorrect. While legal assistance may be helpful, designating a healthcare surrogate does not necessarily require an attorney.
D. Incorrect. The choice of a healthcare surrogate is a personal decision, and the individual can choose any trusted person to fulfill this role, not just a family member.

A.Restraints should never be applied directly on the skin or under clothing, as this can cause irritation, pressure injuries, and make it difficult for the nurse to assess skin integrity. Restraints should be placed over the client's clothing to reduce friction and protect the skin.

B.Positioning the client in a sitting or semi-Fowler's position is preferred as it promotes comfort, minimizes the risk of aspiration, and allows the nurse to monitor the client's airway, breathing, and circulation more effectively. Lying flat can increase discomfort and respiratory difficulty, especially if the client is aggressive or agitated.

C.Restraints should never be tied to movable parts, like bed rails, as this could result in injury if the bed rail is moved up or down. Restraints should be tied to a non-movable part of the bed frame to ensure stability and prevent accidental tightening or loosening that could harm the client.

D.A belt restraint should be placed across the client’s waist or hips, not the chest, as a chest restraint can impede respiratory function, especially in an aggressive client who may be physically exerting themselves. The restraint should secure the client’s lower body to prevent them from standing or moving excessively, while still allowing safe breathing and circulation.