A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Preoxygenating the client with 100% oxygen for up to 3 minutes helps prevent hypoxia during suctioning. 2. COPD patients are at higher risk for hypoxia due to impaired gas exchange. 3. Preoxygenation helps maintain oxygen saturation levels and reduces the risk of complications. 4. This action supports safe and effective nasotracheal suctioning in clients with COPD and an artificial airway. Summary: - Option A: Performing suctioning for up to four passes can increase the risk of hypoxia and mucosal damage. - Option B: Applying suction to the catheter during advancement can cause trauma and increase the risk of infection. - Option D: Limiting each suction pass to 25 seconds may not provide adequate time for effective suctioning in clients with COPD and artificial airways.

Correct Answer: A

Rationale: In the context of a client with dehydration, oral health is crucial as dehydration can lead to dry mouth and oral complications. The correct answer, option A, "Remind client to avoid commercial mouthwashes," is within the scope of practice for an LPN/LVN as it involves providing education on avoiding potentially drying agents that could exacerbate oral dryness. Option B, "Encourage mouth rinsing with warm saline," while beneficial for oral health, may require a higher level of assessment and decision-making that is typically within the scope of an RN rather than an LPN/LVN. Option C, "Assess lips, tongue, and mucous membranes," involves a comprehensive assessment that goes beyond the LPN/LVN scope of practice, as it requires advanced clinical judgment and interpretation. Option D, "Provide mouth care every 2 hours while the client is awake," involves direct patient care that may be beyond the scope of practice for an LPN/LVN without specific delegation and supervision, as it requires more frequent monitoring and assessment. Understanding the scope of practice is essential for all nursing roles to ensure safe and effective care delivery. LPNs/LVNs play a valuable role in the healthcare team, but it is important for them to know their limitations and when to involve higher-level providers for certain interventions.

Correct Answer: B

Rationale: In this scenario, the correct action to take is to review the client's morning calcium level (Option B). This is because the client is exhibiting signs of hypocalcemia, which can manifest as decreased blood pressure, heart rate, and facial twitching. Calcium plays a crucial role in cardiac function and neuromuscular excitability, so monitoring calcium levels is essential in this situation. Option A (Reassess the client’s blood pressure and heart rate) could be a temporary measure, but it does not address the underlying cause of the symptoms. Option C (Request a neurologic consult today) is not the immediate priority because the symptoms are more indicative of a metabolic issue like hypocalcemia rather than a primary neurological problem. Option D (Check the client's pupillary reaction to light) is not relevant to the symptoms presented and does not address the potential hypocalcemia. In an educational context, this question highlights the importance of recognizing and responding to electrolyte imbalances such as hypocalcemia promptly. Understanding the clinical manifestations of various electrolyte disturbances is crucial for nurses to provide safe and effective care to their patients. By choosing the correct intervention, nurses can help prevent further complications and promote positive patient outcomes.

Correct Answer: A

Rationale: In the context of a client with diabetic ketoacidosis (DKA), delegating the task of checking the fingerstick glucose every hour to the nursing assistant is appropriate. This task does not require advanced clinical judgment or interpretation of results and falls within the scope of practice for a nursing assistant. Monitoring glucose levels closely is crucial in managing DKA as it helps in assessing the effectiveness of treatment and detecting any fluctuations promptly. Recording intake and output every hour, checking vital signs every 15 minutes, and assessing for indicators of fluid imbalance are tasks that require a higher level of clinical judgment and interpretation, thus should not be delegated to a nursing assistant. These activities involve assessing for subtle changes in the patient's condition, which necessitates a deeper understanding of the pathophysiology of DKA and its potential complications. Educationally, understanding the rationale behind delegation in the context of DKA is essential for nurses to provide safe and effective care. It underscores the importance of matching tasks with the appropriate skill level of personnel to optimize patient outcomes and prevent errors. Nurses need to prioritize tasks based on the complexity and criticality of the situation, ensuring that each team member functions within their scope of practice to deliver comprehensive care.

Correct Answer: D

Rationale: In the context of pharmacology and medical-surgical care, understanding the factors that contribute to a long and healthy life is essential for healthcare professionals. The correct answer, "D) Interest in life," is rooted in the concept of psychosocial well-being and its impact on overall health. Having a genuine interest in life promotes mental and emotional health, which in turn can positively influence physical well-being. This option emphasizes the importance of maintaining a positive outlook, engaging in activities that bring joy and fulfillment, and fostering social connections. Option A, "A diet high in animal fat, cholesterol, and calories," is incorrect because such a diet is associated with various health risks, including cardiovascular disease, obesity, and metabolic disorders. Healthcare providers emphasize the importance of a balanced diet rich in fruits, vegetables, whole grains, and lean proteins for optimal health. Option B, "Early retirement from work," is incorrect as there is no direct correlation between retirement age and longevity. Factors such as financial stability, social engagement, and continued intellectual stimulation play a more significant role in overall health and well-being. Option C, "Vigorous physical activity once a week," while promoting exercise, is not sufficient for maintaining a long and healthy life. Regular physical activity, along with a balanced diet, adequate sleep, stress management, and preventive healthcare measures, are key components of a healthy lifestyle. Educationally, this question underscores the holistic approach to healthcare, highlighting the interconnectedness of physical, mental, and emotional well-being in promoting longevity and quality of life. It emphasizes the significance of psychosocial factors in health outcomes and reinforces the importance of patient-centered care that addresses the diverse needs of individuals beyond just physical symptoms.