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

Explanation

A. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect

catheterized specimens: This instruction is incorrect for a 24-hour urine collection. Catheterized specimens are not typically used for creatinine clearance tests, and the nurse should not be notified when the bladder is full.
B. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours for the next 24 hours: This instruction is incorrect for a 24-hour urine collection. Creatinine clearance
tests require collection of all urine produced over a 24-hour period, not just specimens at specific intervals.
C. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours: This is the correct instruction for a 24-hour urine collection. The client should begin by discarding the first voided urine and then collect all subsequent urine produced over the next 24 hours, including the urine from the specified time.

D. Cleanse around the meatus, discard the first portion of voiding, and collect the rest in a sterile bottle: This instruction is not appropriate for a 24-hour urine collection. It describes a procedure for collecting a clean-catch urine sample, which is different from a 24-hour urine collection for creatinine clearance.

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?

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Naxlex Comprehensive Predictor Exams

The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Correct Answer is C

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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