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    HESI RN EXIT 3 PROCTORED EXAM

    The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

    Explanation & Rationale

    A. Apply a water-soluble lubricant to the catheter. Lubricating the suction catheter can facilitate insertion, but applying a lubricant is not the primary action needed to address excessive drooling. Additionally, water-soluble lubricants may not provide adequate protection against potential splashes or droplets. B. Wear protective goggles while performing the procedure. Excessive drooling in a client with ALS may increase the risk of exposure to saliva and potential aerosolized droplets during suctioning. Wearing protective goggles helps prevent exposure to bodily fluids and reduces the risk of infection for the nurse. C. Instill 3 mL of normal saline before suctioning. Instilling normal saline before suctioning is not typically indicated for oral suctioning in a client with excessive drooling. This action may increase the risk of aspiration and is unnecessary for managing drooling. D. Instruct the client to cough as the suction tip is removed. Instructing the client to cough is not appropriate for oral suctioning. Coughing may increase the production of saliva and exacerbate drooling. Additionally, this action does not address the nurse's safety during the suctioning procedure.

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