Nokea
A client is post-operative laryngectomy for cancer of the larynx. Which nursing diagnosis would be the priority for this client?
- A. Disturbed body image related to major changes in the structure and function of the larynx
- B. Ineffective airway clearance related to excess mucus in airway, due to surgical procedure
- C. Imbalanced nutrition less than body requirement related to the inability to have food intake, due to dysphagia
- D. Impaired verbal communication related to inability to talk, due to removal of larynx
Correct Answer: B
Rationale: Ineffective airway clearance is the priority post-laryngectomy due to the risk of mucus obstruction in the new airway (stoma), which can be life-threatening.
You may also like to solve these questions
The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:
- A. Measure the urinary output
- B. Check the vital signs
- C. Encourage increased fluid intake
- D. Weigh the client
Correct Answer: B
Rationale: Mental confusion in diabetes insipidus may indicate severe dehydration or electrolyte imbalance, so checking vital signs is the priority to assess stability.
The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
- A. Use a small hand-held hair dryer set on medium heat
- B. Place a small heater near the child's bed
- C. Turn the child at least every 2 hours
- D. Allow one side to dry before changing positions
Correct Answer: C
Rationale: Turning the child every 2 hours ensures even drying of the cast and prevents pressure sores, promoting comfort and healing.
A child who ingested 18 500-mg acetaminophen tablets 30 minutes ago is seen in the ED. Which of these orders should the nurse do first?
- A. activated charcoal per pharmacy
- B. start an IV with D5W to keep the vein open
- C. gastric lavage PRN
- D. acetylcysteine (Mucomyst) for age per pharmacy
Correct Answer: A
Rationale: Activated charcoal is the priority within 1 hour of acetaminophen overdose to reduce absorption, followed by acetylcysteine to prevent liver damage.
A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client's cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is:
- A. Alteration in coping related to pain
- B. Potential for injury related to precipitate delivery
- C. Alteration in elimination related to anesthesia
- D. Potential for fluid volume deficit related to NPO status
Correct Answer: B
Rationale: At 8 cm dilation with complete effacement, the client is in advanced labor, and the risk of precipitate delivery is high, posing a potential for injury.
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?
- A. Reinsert the protruding organ and cover with 4x4s
- B. Cover the wound with a sterile 4x4 and ABD dressing
- C. Cover the wound with a sterile saline-soaked dressing
- D. Apply an abdominal binder and manual pressure to the wound
Correct Answer: C
Rationale: Covering the eviscerated wound with a sterile saline-soaked dressing keeps the protruding organs moist and prevents infection until surgical repair.