Nokea
The client who has undergone a radical neck dissection and tracheostomy for cancer of the larynx is being discharged. Which discharge instructions should the nurse teach? Select all that apply.
- A. The client will be able to speak again after the surgery area has healed.
- B. The client should wear a protective covering over the stoma when showering.
- C. The client should clean the stoma and then apply a petroleum-based ointment.
- D. The client should use a humidifier in the room.
- E. The client can get a special telephone for communication.
Correct Answer: B,D,E
Rationale: Showering protection (B), humidifiers (D), and special phones (E) support tracheostomy care. Speech (A) is lost permanently, and petroleum ointment (C) risks infection.
You may also like to solve these questions
The ABG analysis results reveal that the client's partial pressure of arterial carbon dioxide (PaCO2) is 65 mm Hg. The nurse recognizes that this is abnormal because normal PaCO2 levels fall between which values?
- A. 7.35 and 7.45
- B. 80 and 100 mm Hg
- C. 35 and 45 mm Hg
- D. 22 and 26 mm Hg
Correct Answer: C
Rationale: Normal PaCO2 levels are 35 to 45 mm Hg; a value of 65 mm Hg indicates hypercapnia, common in COPD.
An adult is admitted with chronic obstructive pulmonary disease [COPD]. The nurse notes that he has neck vein distention and slight peripheral edema. The practical nurse notifies the registered nurse and continues frequent assessments because the nurse knows that these signs signal the onset of which of the following?
- A. Pneumothorax
- B. Cor pulmonale
- C. Cardiogenic shock
- D. Left-sided heart failure
Correct Answer: B
Rationale: Neck vein distention and peripheral edema indicate right-sided heart failure, or cor pulmonale, caused by pulmonary hypertension in COPD.
When the nurse is instructing the client on the effectiveness of oseltamivir (Tamiflu), which of the following instruction points is essential?
- A. Tamiflu must be started within 12 to 24 hours of the first symptoms.
- B. Tamiflu must be taken on an empty stomach to aid in absorption.
- C. Tamiflu affects the liver; liver enzymes are assessed before administration.
- D. Tamiflu is most effective when administered intranasally.
Correct Answer: A
Rationale: Oseltamivir is most effective when started within 12 to 24 hours of symptom onset, as it inhibits viral replication early.
The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first?
- A. Check the tubing for any kinks.
- B. Suction the airway for secretions.
- C. Assess the lip line of the ET tube.
- D. Sedate the client with a muscle relaxant.
Correct Answer: A
Rationale: High airway pressure may result from kinks (A), a common cause requiring immediate check. Suctioning (B), lip line (C), and sedation (D) follow if needed.
While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
- A. Suction deeper to pick up secretions
- B. Gently withdraw suction tubing to allow suction or coughing out of mucus
- C. Remove the suction as quickly as possible
- D. Put the suction tube in and out several times to pick up secretions
Correct Answer: C
Rationale: Removing the suction quickly allows the client to cough out mucus naturally, preventing irritation or trauma.