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The nurse needs nasotracheal suctioning. The nurse explains the procedure to the client and performs hand hygiene. Prioritize the nurse's remaining actions to perform the nasotracheal suctioning by placing each step in the correct order.
- A. Prepare suction supplies and equipment and pour sterile saline into a sterile container.
- B. Place finger over suction control port of catheter and suction intermittently while withdrawing the catheter.
- C. Put on sterile gloves.
- D. Lubricate the catheter with sterile saline, insert into naris, and advance into pharynx.
- E. When the client inhales, advance the catheter into the trachea.
- F. Pick up suction catheter with the dominant hand and attach it to connection tubing; avoid contamination of the glove on the dominant hand.
- G. Place tip into sterile saline container while applying suction to clear secretions from the tubing
Correct Answer: A,C,F,D,E,B,G
Rationale: A: Preparing supplies comes first. C: Sterile gloves maintain asepsis. F: Handling catheter keeps dominant hand sterile. D: Lubrication aids insertion. E: Advancing during inhalation ensures tracheal placement. B: Intermittent suction prevents trauma. G: Clearing tubing prevents reinsertion of secretions.
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The experienced nurse observes the student nurse caring for the client with the wet plaster cast illustrated. Which conclusion by the experienced nurse is correct?
- A. The student should not be touching the plaster cast because it is wet.
- B. The student should be using a pillow to lift the client's casted extremity.
- C. The student is correctly handling a wet plaster cast with the palms.
- D. The student should be using fingers and not the palms to handle the cast.
Correct Answer: C
Rationale: C: Using palms prevents indentations in wet casts. A: Wet casts can be touched to reposition. B: Pillows limit inspection of the cast underside. D: Fingers cause pressure points.
A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:
- A. the client reports no episodes of awakening during the night.
- B. the client falls asleep within 1 hour of going to bed.
- C. the client reports satisfaction with his amount of sleep.
- D. the client rates sleep as an 8 or more on the visual analog scale.
Correct Answer: B
Rationale: An expected outcome is that the client falls asleep shortly after going to bed.
Which of the following devices may be applicable to a bedridden patient to address potential venous insufficiency? A .Shear-reducing mattress B. Sequential compression devices C. Compression stockings D.Non-skid socks
- A. B and C
- B. A and D
- C. B and D
- D. A and C
Correct Answer: A
Rationale: For a client with venous insufficiency, sequential compression devices (SCDs) and compression stockings can be applied to improve venous return from the lower extremities.
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
- A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
- B. taking a cool shower and drinking a hot cup of tea
- C. watching TV nightly until midnight
- D. getting a back rub and drinking a glass of warm milk
Correct Answer: D
Rationale: A back rub and warm milk promote relaxation and sleep. Vigorous exercise, cool showers, hot tea, and late TV watching are stimulating and disrupt sleep.
Using the FLACC pain scale, how should the LPN document pain for a non-verbal client with these findings: 1.Face-occasional grimacing 2.Legs-relaxed 3.Activity-Squirming 4.Cry-moans and whimpers 5.Consolability-distractible
- A. 5
- B. 4
- C. 3
- D. 8
Correct Answer: B
Rationale: The points add up like this: Face-1 Legs-0 Activity-1 Cry-1 Consolability-1 Total pain score-4