Question

Which client assessment should the nurse perform during nasopharyngeal suctioning?

Answer 1

Correct Answers:

Observe the client's skin and mucous membranes

Rationale :

👀Observing the skin and mucous membranes during nasopharyngeal suctioning helps assess for hypoxia and hydration, which can quickly change during suctioning.

💧Mucous membrane color can indicate oxygenation status and guide the need to pause or stop suctioning.

🩺Checking bowel sounds and pedal pulses are unrelated to this airway-focused procedure.

💦Skin turgor checks for hydration, but it is not relevant to immediate airway monitoring.

📌Core Message

During nasopharyngeal suctioning, monitor skin and mucous membranes to detect oxygenation changes.

Answer 2

Correct Answers:

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

Rationale :

🕘Charting a late event as a “late entry” maintains documentation integrity and legal compliance.

📆Clearly labeling entries made after the fact ensures an accurate, traceable medical record.

🚫Requesting deletion or addendum is not necessary for simple late charting of routine care.

📲Creating electronic corrections may not apply unless errors or wrong entries occurred, not just omissions.

📌Core Message

Label after-time documentation as a “late entry” to maintain accurate records.

Answer 3

Correct Answers:

Positions the head with the chin tilted slightly downward.

Rationale :

🛏️Elevating the head of the bed to only 60 degrees is inadequate for clients at risk for aspiration during feeding.

👄Chin-down positioning and food on the unaffected side are correct techniques for stroke patients.

🧘‍♂️Resting before feeding helps reduce fatigue and lowers aspiration risk.

⚠️Aspiration precautions require optimal positioning—usually upright at 90 degrees.

📌Core Message

Stroke clients need to be fed in a fully upright position to reduce aspiration risk.

Answer 4

Correct Answers:

Ask the client what is causing the grimacing.

Rationale :

🤨Asking what is causing the grimace opens communication without assuming pain or forcing intervention.

📉The discrepancy between nonverbal cues and verbal denial requires clarification to guide safe care.

💊Administering PRN meds or reviewing prescriptions without understanding the situation could be inappropriate.

🔍Monitoring alone delays response and doesn't resolve the observed discomfort.

📌Core Message

Always clarify nonverbal cues by asking directly when a client’s behavior contradicts their words.

Answer 5

Correct Answers:

Washes hands before handling the needle and syringe.

Rationale :

🧼Hand hygiene is the foundation of standard precautions, preventing contamination before medication handling.

🧤Gloves are not routinely needed at home unless there is a risk of blood exposure.

🚫Removing the needle from the syringe increases the risk of needle-stick injuries.

😷Masks are unnecessary unless there is potential exposure to respiratory secretions.

📌Core Message

Handwashing is the most basic yet critical step in maintaining standard precautions.

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 :

🦠Monitoring the client's white blood cell (WBC) count is essential because an elevated WBC count is a primary indicator of infection or systemic inflammatory response.

🔬Sending wound drainage for culture and sensitivity helps identify the specific pathogen causing the infection and determines the most effective antibiotic therapy.

🚪Instituting contact precautions is critical to prevent the spread of MRSA, a highly contagious and antibiotic-resistant organism, to others.

🧴Standard infection control measures such as hand hygiene are not sufficient alone for MRSA, which requires gloves and gown when entering the client’s room.

📉A low-bacteria diet is not indicated in the management of MRSA since MRSA is not foodborne, and dietary changes do not impact the organism's spread or resolution.

📌Core message

Include monitoring labs, wound cultures, and contact precautions in care plans for clients with suspected MRSA.

Answer 7

Correct Answers:

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

Rationale :

🗣️Acknowledging the client's frustration demonstrates the use of therapeutic communication, which helps validate their emotional experience and build trust.

🧩Clients recovering from a CVA often feel a loss of independence, and the nurse’s empathetic response supports psychosocial adjustment.

😤Anger and cursing may be signs of emotional distress or depression, and confronting them harshly or redirecting without empathy can damage the nurse-client relationship.

🧠Teaching or instruction (like giving a class or correcting technique) during a moment of high emotional frustration is not effective or appropriate.

🤝Empathy allows the nurse to build rapport and opens the door for more productive rehabilitation engagement.

📌Core message

Use empathetic statements to support clients expressing frustration after a stroke.

Answer 8

Correct Answers:

Record a palpable systolic pressure of 90 mm Hg.

Rationale :

💓Palpation of blood pressure involves inflating the cuff until the radial pulse disappears, which indicates the systolic pressure.

🖐️The point at which the radial pulse becomes absent—90 mm Hg in this case—should be documented as the systolic reading.

📏Palpation does not provide diastolic pressure, so no further inflation is necessary once systolic pressure is found.

🛑Releasing the valve immediately or documenting the absence of the pulse are not the correct procedural steps and indicate a misunderstanding of the technique.

📚Inflating further to 120 mm Hg is unnecessary since the target systolic pressure has already been detected via pulse disappearance.

📌Core message

Document the systolic pressure at the point the radial pulse disappears during palpation.

Answer 9

Correct Answers:

Well approximated incision site.

Rationale :

🧵A well-approximated incision means the wound edges are aligned without gaps, indicating effective surgical healing.

🩹This is a normal postoperative finding and shows that the tissue is beginning to regenerate and the risk for infection is reduced.

🧫Eschar and slough are signs of necrosis or infection, which are not normal healing characteristics at this stage.

💉Serosanguineous exudate with erythema may be seen early post-op, but at one week post-surgery, persistent drainage and redness suggest possible complications.

🌱Beefy red granulation tissue is associated more with open wound healing or secondary intention, not a surgical incision healing by primary intention.

📌Core message

A healing surgical incision should have well-approximated edges without signs of infection.

Answer 10

Correct Answers:

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

Rationale :

✅Offering therapeutic touch with a gentle question invites the client to express their emotions in a safe and supportive way.

🗨️This approach promotes emotional exploration, which can help relieve distress and strengthen the nurse-client relationship.

🚫Saying "this is a bad time" or "I'll come back later" closes communication and does not acknowledge the client’s immediate emotional needs.

🧍‍♂️Hugging the client or providing physical comfort without consent can violate professional boundaries, even if well-intended.

🩺The nurse’s goal in emotional situations is to create a nonjudgmental environment for the client to express and process feelings.

📌Core message

Use open-ended therapeutic communication and appropriate nonverbal cues when clients show emotional distress.

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 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?

4 :
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?

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 nurse include 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 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?

4 : 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?

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 nurse include 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 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?

4 :
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?

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 nurse include 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?