Nokea
A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?
- A. Patency of the intravenous line
- B. Level of pain
- C. Integrity of the dressing
- D. Need for suctioning
Correct Answer: D
Rationale: The correct answer is D: Need for suctioning. After a laryngectomy, maintaining a clear airway is crucial to prevent aspiration and ensure proper oxygenation. Suctioning helps remove secretions and maintain airway patency. Monitoring for signs of respiratory distress is essential.
A: Patency of the intravenous line is important but not the priority over airway management.
B: Level of pain is important but not as critical as ensuring a clear airway.
C: Integrity of the dressing is important for wound healing but does not directly impact airway patency.
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What does the nurse give priority to assessing immediately following Mr. Singer’s total laryngectomy?
- A. Elimination patterns
- B. Level of pain
- C. Gag reflex
- D. Respiratory status
Correct Answer: D
Rationale: Respiratory status is critical due to the altered airway anatomy.
Sixty-five-year-old Dominic is being transferred into the postanesthesia care unit (PACU) from the OR. Once there, initial assessment will focus on
- A. Airway, breathing, circulation, and wound site.
- B. Intake, output, and intravenous access.
- C. Abdominal sounds, oxygen level, and level of consciousness.
- D. Pulse oximetry, pupil responses, and deep tendon reflexes.
Correct Answer: A
Rationale: ABCs are prioritized in the immediate postoperative period.
Which teaching strategies should the nurse plan to use for a baby boomer patient (select all that apply)?
- A. Podcast
- B. Role playing
- C. Group teaching
- D. Lecture-discussion
Correct Answer: B
Rationale: The correct answers are 'Role playing,' 'Group teaching,' and 'Lecture-discussion.' Baby boomers often prefer interactive and structured learning environments. Podcasts and games may not resonate as well with this demographic.
While suctioning the endotracheal tube of a client on a ventilator, the nurse notices an increase in the client's heart rate from 86/min to 110/min, with irregularity. What should the nurse do next?
- A. Obtain a cardiology consult.
- B. Suction the client less frequently.
- C. Administer an antidysrhythmic medication.
- D. Perform pre-oxygenation prior to suctioning.
Correct Answer: D
Rationale: The correct answer is D: Perform pre-oxygenation prior to suctioning. In this scenario, the increase in heart rate and irregularity could be due to hypoxia resulting from suctioning. Pre-oxygenation helps to ensure adequate oxygenation before the procedure, preventing hypoxia-induced dysrhythmias. By providing oxygen before suctioning, the nurse can minimize the risk of further complications.
Choice A (Obtain a cardiology consult) is incorrect because immediate action is required to address the potential hypoxia, which can be managed by pre-oxygenation.
Choice B (Suction the client less frequently) is incorrect as it does not address the immediate concern of potential hypoxia leading to dysrhythmias.
Choice C (Administer an antidysrhythmic medication) is incorrect as it is not the initial intervention needed in this situation; addressing the underlying cause of potential hypoxia is essential before considering antidysrhythmic medications.
Priority Decision: The husband and daughter of a Hispanic woman dying from pancreatic cancer refuse to consider using hospice care. What is the first thing the nurse should do?
- A. Assess their understanding of what hospice care services are.
- B. Ask them how they will care for the patient without hospice care.
- C. Talk directly to the patient and family to see if she can change their minds.
- D. Accept their decision since they are Hispanic and prefer to care for their own.
Correct Answer: A
Rationale: The nurse should assess their understanding of hospice care services to ensure they are making an informed decision based on accurate information rather than assumptions or cultural biases.