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?

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

Apply a water-soluble lubricant to the catheter.

Instill 3 mL of normal saline before suctioning.

Wear protective goggles while performing the procedure.

Answer and Explanation

The Correct Answer is D

A. Instruct the client to cough as the suction tip is removed: Clients with ALS might have difficulty coughing effectively, making this action inappropriate.
B. Apply a water-soluble lubricant to the catheter: Lubricant is not necessary for suctioning oral secretions.
C. Instill 3 mL of normal saline before suctioning: Instilling saline is not recommended for oral suctioning due to the risk of aspiration.
D. Wear protective goggles while performing the procedure: Protective goggles are important to prevent splashes from secretions during suctioning.

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Correct Answer is ["A","E","F"]

Explanation

A. Swollen hands: Swelling, particularly in the hands and face, can be a sign of preeclampsia due to increased blood pressure and fluid retention. It should be reported to the healthcare provider for further evaluation.
B. Lack of appetite: While a lack of appetite may occur in pregnancy, it is not a specific indicator of preeclampsia. This symptom is more general and could be caused by a variety of factors.
C. Urinary frequency: Increased urinary frequency is common in pregnancy due to the growing uterus pressing on the bladder and is not a specific indicator of preeclampsia.
D. Chills and fever: These symptoms are not typical indicators of preeclampsia. They might suggest an infection or other condition, but they are not specifically associated with preeclampsia.
E. Headache: Severe or persistent headaches can be a sign of preeclampsia, as high blood pressure affects the vascular system and may lead to headaches. This should be reported to assess for potential preeclampsia.
F. Blurred vision: Blurred vision is a significant symptom of preeclampsia related to high blood pressure and potential damage to the blood vessels in the eyes. It is a key indicator that should be reported to the healthcare provider.

A. Suction cannister B. Tape C. Nasal cannula D. Sterile water E. Flowmeter F. Humidifier bottle G. Lamb's wool

Correct Answer is ["C","E"]

Explanation

Rationale:

A. Suction cannister
A suction cannister is not required for administering oxygen. It is used for removing secretions from the airway, which is not indicated for this situation.

B. Tape
Tape is not necessary for starting oxygen therapy. It is generally used for securing dressings or IV lines, not for oxygen administration.

C. Nasal cannula
A nasal cannula is the device used to administer oxygen to the patient at 3 L/minute, as ordered. It delivers a constant flow of oxygen to the patient.

D. Sterile water
Sterile water is not needed for the administration of oxygen via a nasal cannula. It is used for procedures requiring sterile conditions, such as wound care.

E. Flowmeter
A flowmeter is essential for regulating the amount of oxygen delivered to the patient. It controls the flow rate of the oxygen, which is set at 3 L/minute for this client.

F. Humidifier bottle
A humidifier bottle is not required for a low-flow oxygen therapy such as 3 L/minute via nasal cannula. It is used for high-flow oxygen therapies.

G. Lamb's wool
Lamb's wool is not relevant for oxygen therapy. It is used for padding and comfort, which is not necessary for this task.

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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

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