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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?

A.

Instill 3 mL of normal saline before suctioning.

B.

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

C.

Apply a water-soluble lubricant to the catheter.

D.

Wear protective goggles while performing the procedure.

E.

Wear protective goggles while performing the procedure.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Instill 3 mL of normal saline before suctioning. This choice is not appropriate for suctioning excessive drooling in a client with ALS. Instilling normal saline would introduce additional fluid into the oral cavity, potentially worsening the problem by increasing the amount of secretions. The goal of suctioning is to remove excess saliva and maintain a clear airway.

Choice B rationale:

Instruct the client to cough as the suction tip is removed. Instructing the client to cough during suctioning is not a recommended practice. It may cause discomfort and can lead to an increased risk of aspiration as the client might inhale while coughing during the procedure.

Choice C rationale:

Apply a water-soluble lubricant to the catheter. Applying a water-soluble lubricant to the suction catheter is a common practice to facilitate the passage of the catheter and minimize irritation to the client's oral tissues. While it is a helpful step, it is not the primary action that should be taken to ensure the safety of the procedure.

Choice D rationale:

Wear protective goggles while performing the procedure. This is the correct choice. When suctioning a client's oral cavity, especially when dealing with excessive drooling or secretions, it is essential for the nurse to wear protective goggles. These goggles protect the nurse's eyes from potential exposure to the client's bodily fluids, reducing the risk of infection transmission.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale:

This statement is incorrect. Suicidal ideation is not a diagnosis in itself but rather a symptom or thought process associated with various mental health conditions.

Choice B rationale:

This statement is incorrect. Suicidal ideation can occur in individuals of all age groups, not just in older adults. It is not limited to any specific age demographic.

Choice C rationale:

This statement is incorrect. Suicidal ideation does not always involve a detailed plan for self-harm. It can range from fleeting thoughts of self-harm to more detailed plans, but the severity can vary widely.

Choice D rationale:

This statement is accurate. Suicidal ideation can be a symptom of various underlying mental health conditions, including depression, anxiety disorders, bipolar disorder, and others. It involves thoughts of self-harm or suicide, which may or may not be accompanied by specific plans.

Correct Answer is C

Explanation

The correct answer is: C. Bronchospasm.

Metoprolol is a selective beta-1 blocker, primarily affecting the heart, but it can still have some impact on beta-2 receptors in the lungs. In clients with respiratory conditions like asthma or COPD, beta-blockers can trigger bronchospasm, leading to breathing difficulties.

Here's why the other options are less likely to be adverse effects of metoprolol:

  • A. Tachycardia: Metoprolol actually lowers heart rate, so tachycardia is not a typical adverse effect. Instead, bradycardia (slow heart rate) is more common.

  • B. Hyperglycemia: Beta-blockers can sometimes mask symptoms of hypoglycemia, but they don’t directly cause high blood sugar.

  • D. Hyperkalemia: Metoprolol doesn’t significantly affect potassium levels, so hyperkalemia is not a common concern.

Since metoprolol is frequently used in hypertension management, nurses must monitor clients for bradycardia, hypotension, and signs of bronchospasm, especially in individuals with respiratory disorders.

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