Nokea
During the preoperative period, which nursing action will be of greatest priority for a person who is to have a laryngectomy?
- A. Establish a means of communication.
- B. Prepare the bowel by administering enemas until clear.
- C. Teach the client to use an artificial larynx.
- D. Demonstrate the technique for suctioning a laryngectomy tube.
Correct Answer: A
Rationale: Establishing a means of communication is the highest priority preoperatively, as the client will lose the ability to speak post-laryngectomy.
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While withdrawing the suction catheter from a client's tracheostomy tube, which nursing technique is correct?
- A. Remove the catheter slowly.
- B. Push and pull the catheter.
- C. Plunge the catheter up and down.
- D. Twist and rotate the catheter.
Correct Answer: A
Rationale: Removing the catheter slowly while applying intermittent suction ensures effective secretion removal without causing trauma.
The nurse observes the client sitting on the side of the bed with the arms propped on the over-bed table. The chest is barrel shaped and the client is breathing though lips spaced close together and is exhaling slowly. Which concept is priority for this client?
- A. Mobility.
- B. Nutrition.
- C. Activity intolerance.
- D. Oxygenation.
Correct Answer: D
Rationale: Tripod position, barrel chest, and pursed-lip breathing (D) indicate COPD with oxygenation as the priority. Mobility (A), nutrition (B), and activity (C) are secondary.
Which specimen collection technique should the nurse use to correctly obtain the throat culture from the client?
- A. The nurse asks the client to expectorate sputum into a paper cup.
- B. The nurse wipes the inner mouth and tongue with gauze.
- C. The nurse swabs the throat with a sterile cotton applicator.
- D. The nurse collects saliva in a sterile culture cup.
Correct Answer: C
Rationale: A throat culture requires swabbing the pharynx with a sterile cotton applicator to collect a sample from the area most likely to harbor pathogens.
A patient with COPD is reporting depression and thoughts of suicide. The patient states, 'I just feel like ending it all.' You assess the patient's health history and note that the patient was recently started on which medication that could cause this side effect:
- A. Atrovent
- B. Prednisone
- C. Roflumilast
- D. Theophylline
Correct Answer: C
Rationale: Roflumilast is associated with psychiatric side effects, including depression and suicidal thoughts. Other medications (A, B, D) are less commonly linked to these effects.
The nurse is caring for the client diagnosed with end-stage COPD. Which data warrant immediate intervention by the nurse?
- A. The client's pulse oximeter reading is 92%.
- B. The client's arterial blood gas level is 74.
- C. The client has SOB when walking to the bathroom.
- D. Rusty colored sputum.
Correct Answer: D
Rationale: Rusty sputum (D) suggests hemoptysis or infection, a critical finding in end-stage COPD. SpO2 92% (A), PaO2 74 (B), and SOB (C) are expected but less urgent.