Practice Question
Which client assessment should the nurse perform during nasopharyngeal suctioning?
Answer Choices:
Correct Answer:
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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This question is from WGU-Hesi~RN Fundamentals of Nursing which contains 56 questions.
More Questions from This Exam
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?
Answer Choices:
A. Request removal initiated by the Health Information Manager.
B. Create an electronic correction after 1400 notes are officially unlocked.
C. Enter the occurrence after the 1400 notes and identify as "late entry.".
D. Make an electronic addendum following the 1400 documentation.
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?
Answer Choices:
A. Review the pain medications prescribed.
B. Monitor the client's nonverbal behavior.
C. Administer PRN oral pain medication.
D. Ask the client what is causing the grimacing.
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?
Answer Choices:
A. Positions the head with the chin tilted slightly downward.
B. Allows 30 minutes of rest before feeding.
C. Places food on the unaffected side of the mouth.
D. Raises the head of the bed to 60 degrees.
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?
Answer Choices:
A. Wears gloves to dispose of the needle and syringe.
B. Removes needle before discarding used syringes.
C. Dons a face mask before administering the medication.
D. Washes hands before handling the needle and syringe.
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.
Answer Choices:
A. Monitor the client's white blood cell count.
B. Send wound drainage for culture and sensitivity.
C. Institute contact precautions for staff and visitors.
D. Explain the purpose of a low bacteria diet.
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI Exam(s)
- Domain: Hesi Fundamentals of Nursing
- Answer Choices: 4
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