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 D

Explanation

Choice A rationale:

The client being the oldest of their siblings is not a contributing factor related to the development of conduct disorder. Family dynamics such as birth order may have some influence on personality traits, but they are not a primary factor in the development of conduct disorder.

Choice B rationale:

The fact that the client's father lives in the client's home is a family dynamic, but it does not necessarily contribute to the development of conduct disorder. Other factors related to parenting style, communication, and family interactions play a more significant role in the development of conduct disorder.

Choice C rationale:

The client's mother having asthma is a medical condition and not a family dynamic that directly contributes to the development of conduct disorder. Conduct disorder is more closely associated with social, environmental, and psychological factors.

Choice D rationale:

The presence of several siblings in the family dynamic can contribute to the development of conduct disorder. Increased family size can lead to competition for attention and resources, which may affect the child's behavior and interactions. Sibling relationships and family dynamics are crucial in shaping a child's behavior and psychological well-being.

A. Take out dentures and place in a labeled cup. B. Gently close the eyes. C. Place a small pillow under the head. D. Apply a body shroud. E. Remove resuscitation equipment from the room.

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

Explanation

Choice A rationale:

Taking out dentures and placing them in a labeled cup (Choice A) is a necessary step to ensure the comfort and dignity of the deceased. It helps maintain the appearance and respect for the deceased person.

Choice B rationale:

Gently closing the eyes (Choice B) is a common practice to provide a more peaceful and natural appearance to the deceased. It also prevents the eyes from remaining partially open, which can be distressing for family members.

Choice C rationale:

Placing a small pillow under the head (Choice C) is done to maintain the natural alignment of the head and neck. This helps create a more lifelike appearance and enhances the comfort of the deceased.

Choice E rationale:

Removing resuscitation equipment from the room (Choice E) is essential for maintaining the dignity of the deceased and creating a more peaceful environment for the family. It also helps prevent any distressing reminders of the resuscitation attempt.

Choice D rationale:

Apply a body shroud (Choice D) is not a common practice in preparing the body for viewing by the family. The use of a body shroud may vary based on cultural or religious preferences, but it is not a standard procedure in many healthcare settings.

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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

A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder.Which of the following factors related to family dynamics should the nurse include in the teaching?

Correct Answer is D

Explanation

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

Explanation

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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?