A nurse is preparing to perform nasotracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take?

Apply intermittent suction for 20 to 30 seconds.

Place the catheter in a location that is clean and dry for later use.

Hold the suction catheter with the clean, nondominant hand.

Use surgical asepsis when performing the procedure.

Answer and Explanation

The Correct Answer is D

A. "Apply intermittent suction for 20 to 30 seconds." –
Suctioning should be applied intermittently for no more than 10 to 15 seconds to prevent hypoxia and mucosal damage.
B. "Place the catheter in a location that is clean and dry for later use." –
A suction catheter should not be reused once it has been used; it should be discarded after a single use to prevent infection.
C. "Hold the suction catheter with the clean, nondominant hand." –
The dominant hand should remain sterile and be used to control the suction catheter, while the nondominant hand is used to handle nonsterile equipment.
D. "Use surgical asepsis when performing the procedure." –
Nasotracheal suctioning is a sterile procedure because it involves direct access to the lower airway, requiring surgical asepsis to reduce the risk of infection.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

The first client the nurse should assess is Client 3 (Pulmonary Edema) followed by Client 1 (Hip Fracture).

Rationale:

Client 3 (Pulmonary Edema) – Highest Priority:

1. Pulmonary edema is a life-threatening condition that can impair oxygenation.
2. The client has a history of congestive heart failure (CHF) and a chest x-ray confirming pulmonary edema.
3. Immediate assessment is required to evaluate for respiratory distress, oxygenation status, and potential need for diuretics or oxygen therapy.

Client 1 (Hip Fracture) – Second Priority:

1. The x-ray confirms a fractured femoral neck, which can cause severe pain, bleeding, and immobility.
2. The nurse must assess for circulation, sensation, and movement (CSM) of the affected limb and manage pain.
3. While this is urgent, it is not as immediately life-threatening as pulmonary edema.

Priority Order (Using ABCs & Maslow’s Hierarchy):

Client 3 – Pulmonary Edema (Airway/Breathing concern)
2. Client 1 – Hip Fracture (Risk for bleeding, pain, mobility issues)
3. Client 4 – Low Potassium (Risk for cardiac arrhythmias, needs electrolyte management)
4. Client 6 – Poor Diabetes Control (HbA1c 9%, requires education & glucose monitoring)
5. Client 5 – Malnutrition (Prealbumin 12 mg/dL, needs nutrition support for wound healing)
6. Client 2 – Hyperlipidemia (Not an immediate concern, requires long-term management)

A. Community health nurse B. Respite care provider C. Dietician D. Occupational therapist

Correct Answer is D

Explanation

A. A community health nurse can provide education, medication management, and health monitoring, but they do not specifically focus on ADL assistance.
B. Respite care provides temporary relief for caregivers, but it does not directly help the client develop skills to maintain independence.
C. A dietitian focuses on nutritional needs and meal planning, but this does not directly address the increased difficulty with ADLs.

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A nurse is preparing to perform nasotracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take?

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Naxlex Comprehensive Predictor Exams

A nurse in a medical-surgical unit is caring for 6 clients. Exhibits Complete the following sentence by using the lists of options. The first client the nurse should assess is dropdownfollowed bydropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Rationale:

Priority Order (Using ABCs & Maslow’s Hierarchy):

Correct Answer is D

Explanation

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