Which client assessment should the nurse perform during nasopharyngeal suctioning?

Auscultate the bowel sounds in all four quadrants.

Palpate the client's pedal pulse volume bilaterally.

Determine the elasticity of the client's skin turgor.

Observe the client's skin and mucous membranes.

Answer and Explanation

The Correct Answer is D

A. Auscultate the bowel sounds in all four quadrants:

Auscultating bowel sounds is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating gastrointestinal function and is not a priority during airway management procedures.

B. Palpate the client's pedal pulse volume bilaterally:

Palpating pedal pulse volume is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating peripheral vascular perfusion and is not a priority during airway management procedures.

C. Determine the elasticity of the client's skin turgor:

Assessing skin turgor elasticity is not directly relevant to nasopharyngeal suctioning. This assessment is typically performed to evaluate hydration status and is not a priority during airway management procedures.

D. Observe the client's skin and mucous membranes:

This is the most appropriate assessment during nasopharyngeal suctioning. Observing the client's skin and mucous membranes helps monitor for signs of respiratory distress, such as cyanosis, pallor, or increased respiratory effort. It also allows the nurse to assess the effectiveness of airway clearance and potential complications related to the procedure.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Administering the medication to a client behind a closed curtain:

Administering medication behind a closed curtain is not necessarily a tort. However, it may be a breach of privacy depending on the circumstances and the client's preferences.

B. Enlisting security personnel to assist with restraining the client:

Enlisting security personnel to assist with restraining an agitated client is not inherently a tort. It may be necessary to ensure the safety of the client and healthcare providers, depending on the situation.

C. Informing a client that the medication being administered is a vitamin:

Misinforming a client about the medication being administered is not a tort, but it is unethical and can lead to potential harm if the client does not receive appropriate treatment.

D. Placing a client in restraints without having a healthcare provider's order:

This action constitutes a tort known as false imprisonment. Restraints should only be applied when ordered by a healthcare provider and when necessary to ensure the safety of the client or others. Placing a client in restraints without proper authorization can lead to physical and psychological harm and is a violation of the client's rights.

A. Capillary refill of 2 seconds in the lower right foot. B. Basilar lung sounds that are diminished in the left lung. C. Contraction of the left pupil when light shines in the right eye. D. Active bowel sounds in the lower right quadrant.

Correct Answer is B

Explanation

A. Capillary refill of 2 seconds in the lower right foot:

Capillary refill of 2 seconds in the lower right foot is within normal limits and does not require documentation in a chart-by-exception system, as it is considered an expected finding.

B. Basilar lung sounds that are diminished in the left lung:

Diminished basilar lung sounds in the left lung may indicate a respiratory issue and would be considered a significant finding warranting documentation in a chart-by-exception system.

C. Contraction of the left pupil when light shines in the right eye:

Contraction of the left pupil when light shines in the right eye is an abnormal finding (consensual response), which should be documented in a chart-by-exception system.

D. Active bowel sounds in the lower right quadrant:

Active bowel sounds in the lower right quadrant are within normal limits and do not require documentation in a chart-by-exception system, as they are considered expected findings.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

Correct Answer is D

Explanation

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is B

Explanation

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?