Question

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Answer 1

Correct Answers:

Observe the client's skin and mucous membranes

Rationale :

🔷 During nasopharyngeal suctioning, it's essential to observe the skin and mucous membranes to assess for signs of hypoxia, cyanosis, or distress.

🔷 These indicators can reveal inadequate oxygenation or ineffective suctioning.

🔷 Other assessments like bowel sounds or pedal pulses are not relevant to airway management.

🔷 Monitoring these areas helps guide the effectiveness of the intervention and ensures patient safety.

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Answer 2

Correct Answers:

Enter the occurrence after the 1400 notes and identify as "late entry.".

Rationale :

🔷 A “late entry” is the legally accepted way to document events that occurred earlier in the shift but were missed.

🔷 This maintains record integrity and transparency, essential for legal documentation and patient safety.

🔷 It also preserves chronological accuracy without modifying existing entries.

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Answer 3

Correct Answers:

Ask the client what is causing the grimacing.

Rationale :

🔷 Nonverbal cues like grimacing may indicate pain, discomfort, or emotional distress, even if the client denies it.

🔷 Therapeutic communication requires the nurse to explore observable concerns, not disregard them based on verbal denial.

🔷 Asking directly but gently supports emotional validation, promotes trust, and uncovers the real issue—be it pain, fear, or something else.

🔷 This approach aligns with patient-centered care, which values subjective and objective findings equally.

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Answer 4

Correct Answers:

Raises the head of the bed to 60 degrees.

Rationale :

🔷 A client at risk for aspiration (e.g., post-stroke) should be positioned in high Fowler’s (75–90°) during feeding to maximize gravity assistance in swallowing and reduce aspiration risk.

🔷 A 60° elevation is insufficient, as it does not adequately protect the airway, especially in clients with impaired swallowing or gag reflex.

🔷 Teaching the UAP about correct positioning supports safe feeding practices and protects the client from complications such as aspiration pneumonia

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Answer 5

Correct Answers:

Washes hands before handling the needle and syringe.

Rationale :

🔷 Hand hygiene is the first and most effective defense against healthcare-associated infections.

🔷 Before preparing or administering medications, handwashing ensures that pathogens from surfaces or other patients aren’t transmitted.

🔷 This step must always be performed even when gloves are worn, as gloves are not a substitute for proper hand hygiene.

🔷 Infection control is a key component of standard precautions and is a responsibility shared across all settings and roles.

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Answer 6

Correct Answers:

Monitor the client's white blood cell count.
Send wound drainage for culture and sensitivity.
Institute contact precautions for staff and visitors.

Rationale :

🔷 A. Monitoring WBC identifies trends that may indicate systemic infection progression and effectiveness of treatment.

🔷 B. Culture and sensitivity confirms MRSA and identifies the most effective targeted antibiotic, essential in resistant infections.

🔷 C. Contact precautions are required to prevent MRSA transmission via contaminated hands or equipment; includes gown, gloves, and dedicated equipment.

🔷 These actions are based on evidence-based infection control protocols that reduce hospital-acquired infections and protect staff, patients, and visitors.

🔷 Explaining a “low bacteria diet” is irrelevant to MRSA, which is not foodborne.

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Answer 7

Correct Answers:

"Dressing must be a frustrating experience for you.".

Rationale :

🔷 This response demonstrates empathy and uses therapeutic communication to validate the client’s frustration without judgment.

🔷 Clients recovering from CVA often experience loss of independence, and dressing can be both physically and emotionally challenging.

🔷 Acknowledging frustration helps to de-escalate anger and opens the door for further collaborative discussion about adaptive strategies.

🔷 Avoiding confrontation preserves the therapeutic relationship and supports psychosocial well-being.

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Answer 8

Correct Answers:

Record a palpable systolic pressure of 90 mm Hg.

Rationale :

🔷 Palpation of blood pressure detects only the systolic reading—the point at which the pulse returns after inflation.

🔷 This method is used when Korotkoff sounds are inaudible, such as in hypotensive states or loud environments.

🔷 Recording the systolic pressure based on palpation provides essential data for fluid status, perfusion, and response to therapy.

🔷 No diastolic reading is documented with palpation.

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Answer 9

Correct Answers:

Well approximated incision site.

Rationale :

🔷 “Well approximated” means the wound edges are closed, aligned, and healing without signs of infection, dehiscence, or drainage.

🔷 It reflects successful healing in the proliferative phase of wound repair.

🔷 Other findings like erythema or slough may indicate delayed healing or infection.

🔷 This is the ideal finding one week post-op, and should be documented as a normal healing progression.

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Answer 10

Correct Answers:

While touching the client's forearm, asks, "Would you like to talk about it?"

Rationale :

🔷 This response combines gentle therapeutic touch with an invitation to express emotions, which supports emotional catharsis.

🔷 Emotional support is part of holistic care and helps clients manage grief, fear, or anxiety, which may interfere with healing.

🔷 Avoiding the conversation may result in emotional suppression, worsening distress.

🔷 Nurses must be skilled in recognizing and responding to both verbal and nonverbal cues of emotional suffering.

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QLexNursing

1 :
Which client assessment should the nurse perform during nasopharyngeal suctioning?

2 :
After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

3 :
The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain.
Which intervention should the nurse implement first?

4 :
The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.Which action by the UAP should the nurse recognize indicates the need for additional teaching?

5 :
The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

6 :
A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer.The client is suspected to have a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurseinclude in the plan of care?
Select all that apply.

7 :
A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm.
When the nurse enters the room, the client is struggling to put on a shirt and curses at the nurse. Which response is best for the nurse to provide?

8 :
The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

9 :
The nurse is caring for a client one week post-surgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

10 :
The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

QLexNursing

1 : Which client assessment should the nurse perform during nasopharyngeal suctioning?

2 : After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

3 : The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain.Which intervention should the nurse implement first?

4 : The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.Which action by the UAP should the nurse recognize indicates the need for additional teaching?

5 : The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

6 : A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer.The client is suspected to have a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurseinclude in the plan of care?Select all that apply.

7 : A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm.When the nurse enters the room, the client is struggling to put on a shirt and curses at the nurse. Which response is best for the nurse to provide?

8 : The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

9 : The nurse is caring for a client one week post-surgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

10 : The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

1 :
Which client assessment should the nurse perform during nasopharyngeal suctioning?

2 :
After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

3 :
The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain.
Which intervention should the nurse implement first?

4 :
The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.Which action by the UAP should the nurse recognize indicates the need for additional teaching?

5 :
The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

6 :
A client who is paraplegic is admitted with a foul-smelling drainage from a sacral ulcer.The client is suspected to have a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which nursing intervention(s) should the nurseinclude in the plan of care?
Select all that apply.

7 :
A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm.
When the nurse enters the room, the client is struggling to put on a shirt and curses at the nurse. Which response is best for the nurse to provide?

8 :
The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

9 :
The nurse is caring for a client one week post-surgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

10 :
The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?