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The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for
fifteen seconds, large amounts of thick yellow secretions return. What action should the
nurse implement next?
a.) Encourage the client to cough to help loosen secretions.
b.) Advise the client to increase the intake of oral fluids.
c.) Rotate the suction catheter to obtain any remaining secretions.
d.) Re-oxygenate the client before attempting to suction again. - ANSWERS-d.) Re-
oxygenate the client before attempting to suction again.
Rationale: Nasotracheal suctioning should not be continued for longer than ten to fifteen
seconds, since the client's oxygenation is compromised during this time. Additional
suctioning may continue after the client has received oxygen.
The nurse witnesses the signature of a client who has signed an informed consent.
Which statement best explains this nursing responsibility?
A.) The client voluntarily signed the form.
B.) The client fully understands the procedure.
, C.) The client agrees with the procedure to be done.
D.) The client authorizes continued treatment. - ANSWERS-a.) The client voluntarily
signed the form.
Rationale: The nurse signs the consent form to witness that the client voluntarily signs
the consent, that the client's signature is authentic, and that the client is otherwise
competent to give consent. It is the healthcare provider's responsibility to ensure that
the client fully understands the procedure. The nurse's signature does not indicate that
the client agrees to or authorizes treatment.
At the time of the first dressing change, the client refuses to look at her mastectomy
incision. The nurse tells the client that the incision is healing well, but the client refuses
to talk about it. Which is the best response to this client's silence?
A.) "It is normal to feel angry and depressed, but the sooner you deal with this surgery,
the better you will feel."
B.) "Looking at your incision can be frightening, but facing this fear is a necessary part
of your recovery."
C.) "It is OK if you don't want to talk about your surgery. I will be available when you are
ready."
D.) "I will ask a woman who has had a mastectomy to come by and share her
experiences with you." - ANSWERS-C.) "It is OK if you don't want to talk about your
surgery. I will be available when you are ready."
Rationale: When a client is reluctant to look at a surgical wound or refuses to talk about
the surgery, the nurse should reflect that these feelings are OK and that the nurse is
available when the client is ready. Such a response displays sensitivity and
understanding without judging the client. On the other hand, telling a client how she
should feel is judgmental and insensitive.
A client who has a sinus infection is receiving a prescription for amoxicillin/clavulanate
potassium (Augmentin) 500 mg PO q8 hours. The available form is 250 mg
amoxicillin/125mg clavulanate tablets. How many tablets should the nurse administer
for each dose? (Enter numeric value only.) - ANSWERS-2
Rationale:
Using Desired/Available Formula—> 500mg/250mg x 1 tablet = 2