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?

Instill 3 mL of normal saline before suctioning.

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

Apply a water-soluble lubricant to the catheter.

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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Correct Answer is A

Explanation

Choice A rationale:

Observing for signs of depression is the most important intervention for the nurse to include in the client's plan of care. This patient has a history of struggling with weight management, diabetes mellitus, and hypertension, and is now approved for gastroplasty. Weight management surgery can have significant psychological implications, and patients may experience depression or other emotional issues. Identifying signs of depression and providing appropriate support and resources is crucial for the client's overall well-being and successful outcomes.

Choice B rationale:

Monitoring for urinary incontinence is not the top priority in this case. While it's important to assess and address urinary incontinence when necessary, it is not the most critical concern for a client undergoing gastroplasty. Depression and post-surgical complications related to weight management surgery take precedence.

Choice C rationale:

Providing a wide variety of meal choices is not the most important intervention at this stage. After gastroplasty, dietary choices are typically restricted, and the focus is on a controlled and healthy diet. The priority is addressing the psychological and emotional aspects of the client's care, as well as monitoring for surgical complications.

Choice D rationale:

Applying sequential compression stockings is not the most crucial intervention in this situation. While prophylaxis against deep vein thrombosis (DVT) is important, it is not the top priority compared to addressing potential depression and emotional well-being in a client who has struggled with weight management for years.

A. Ask the mother if any visitors were expected to arrive. B. Match ID bands of all infants and mothers on the unit. C. Determine if the newborn is in the nursery. D. Activate the lockdown procedure.

Correct Answer is D

Explanation

The correct answer is D. Activate the lockdown procedure.

Choice A rationale:

Asking the mother about expected visitors is important for later investigation, but it does not address the immediate concern of a potentially missing infant and delays necessary security measures.

Choice B rationale:

Matching ID bands is an essential step in verifying the identity of infants and mothers, but it should follow initial actions to secure the area and prevent possible abduction.

Choice C rationale:

Determining if the newborn is in the nursery is a logical step but not the first priority. The immediate action should be to secure the unit to prevent any potential abductor from leaving.

Choice D rationale:

Activating the lockdown procedure is the first priority to ensure the safety of the infant and prevent any unauthorized individuals from leaving the facility. This step is crucial to quickly address the situation and prevent potential abduction.

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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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Correct Answer is A

Explanation

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Correct Answer is D

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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?