The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

Apply a water-soluble lubricant to the catheter.

Wear protective goggles while performing the procedure.

Instill 3 mL of normal saline before suctioning.

Instruct the client to cough as the suction tip is removed.

Answer and Explanation

The Correct Answer is B

A.   Apply a water-soluble lubricant to the catheter. Lubricating the suction catheter can facilitate insertion, but applying a lubricant is not the primary action needed to address excessive drooling.
Additionally, water-soluble lubricants may not provide adequate protection against potential splashes or droplets.
B.   Wear protective goggles while performing the procedure. Excessive drooling in a client with ALS may increase the risk of exposure to saliva and potential aerosolized droplets during
suctioning. Wearing protective goggles helps prevent exposure to bodily fluids and reduces the risk of infection for the nurse.
C.   Instill 3 mL of normal saline before suctioning. Instilling normal saline before suctioning is not typically indicated for oral suctioning in a client with excessive drooling. This action may increase the risk of aspiration and is unnecessary for managing drooling.
D.   Instruct the client to cough as the suction tip is removed. Instructing the client to cough is not appropriate for oral suctioning. Coughing may increase the production of saliva and exacerbate drooling. Additionally, this action does not address the nurse's safety during the suctioning
procedure.

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Correct Answer is ["C","D","G"]

Explanation

A. The client may be developing sepsis.

Sepsis typically presents with symptoms such as fever, increased heart rate, increased respiratory rate, and altered blood pressure. There is no indication of these signs in the provided data,
making sepsis an unlikely cause for the change in the Glasgow Coma Scale (GCS) score.

B. The client may be dehydrated.

Dehydration can affect cognitive function, but there is no evidence suggesting dehydration in this scenario (e.g., normal heart rate, blood pressure, and no noted intake/output imbalance).
C. The client may have increasing symptoms of head injury.

A decrease in GCS score can indicate worsening head injury symptoms, such as increased intracranial pressure or bleeding.
D. The client may have been sleeping.

Sleeping can temporarily affect the GCS score, particularly the eye-opening component.

E. The client may be improving clinically.

Improvement clinically would likely result in a stable or improved GCS score, not a decrease.

F. The client may require more morphine.

Needing more morphine would typically be due to increased pain, but this should not directly affect the GCS score unless severe pain is causing altered consciousness, which is not indicated here.
G. The client may be experiencing sedative effects of morphine.

Morphine, especially given intravenously, can cause sedation, which could lower the GCS score.

H. The client may need food.

Needing food would not typically cause an immediate change in GCS score unless associated with severe hypoglycemia, which is not indicated by the provided data.

A. Dosage in safe range B. Blood urea nitrogen 17 mg/dl. (6.07 mmol/L) C. Potassium 4.4 mEq/L (4.4 mmol/L) D. No known allergies E. Peripheral IV in large vein F. Used for prophylaxis

Correct Answer is ["A","B","D","E"]

Explanation

A. Dosage in safe range: Ensures that the dosage of vancomycin falls within the acceptable range, minimizing the risk of toxicity.
B. Blood urea nitrogen 17 mg/dl (6.07 mmol/L): Normal BUN levels indicate adequate renal function, which is important for the excretion of vancomycin.
C. Potassium 4.4 mEq/L (4.4 mmol/L): While potassium levels are important for overall health, they are not directly related to the administration of vancomycin.
D. No known allergies: Absence of allergies reduces the risk of adverse reactions to the medication.
E. Peripheral IV in large vein: A peripheral IV in a large vein allows for the administration of vancomycin without complications such as phlebitis or infiltration.
F. While vancomycin is being used for prophylaxis against endocarditis in this case, this alone does not indicate the safety of administering the antibiotic. Other factors such as renal function and absence of allergies are more directly related to the safety of vancomycin administration.

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The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Which may have caused the change in the Glasgow Coma Scale score between 2000 and 2400? Select all that apply.

Correct Answer is ["C","D","G"]

Explanation

Exhibits Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

Correct Answer is ["A","B","D","E"]

Explanation

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