Nokea
The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?
- A. Develop an alternate method of communication.
- B. Encourage oral nutrition on the second postoperative day.
- C. Maintain the client in a low-Fowler's position.
- D. Assess the tracheostomy cuff for leaks.
Correct Answer: A
Rationale: The client with a total laryngectomy is not able to speak. Communication needs to be established using an alternate method. The client typically has difficulty with swallowing due to edema in the immediate postoperative period. Alternate forms of nutrition are used. The tracheostomy cuff is often deflated for periods of time. The head of the bed is maintained in a semi-Fowler's position to decrease edema.
You may also like to solve these questions
The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose?
- A. CBC with differential
- B. Transillumination of the sinus
- C. Nasal culture
- D. Magnetic resonance imaging (MRI)
Correct Answer: B
Rationale: Transillumination and $x$-rays of the sinuses may show a change in the shape of or confirms that there is fluid in the sinus cavity. CBC with differential can note an elevated white blood cell count but not confirm fluid in the sinus cavity. A nasal culture can note bacteria in the nares. An MRI is an expensive procedure which is not typically prescribed for a potential infection and not specifically ordered to identify fluid in thesinus cavity.
The nurse in the walk-in clinic obtains a history of an upper respiratory infection with a red, sore throat. The client has been febrile for 3 days. Which nursing assessment should be stressed?
- A. Lung fields
- B. Voiding
- C. Joint pain
- D. Mentation
Correct Answer: B
Rationale: A pharyngitis occurs from inflammation of the throat, typically from a virus or bacteria. The most serious bacteria are the group A streptococci, commonly referred to as strep throat. Strep throat can have serious cardiac and renal complications,including sepsis. Assessing voiding can be an indication of renal status. Lung fields, joint pain, and mentation are completed in the head-to-toe assessment.
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?
- A. A ventilator
- B. A face mask
- C. A rigid shell
- D. A nasal cannula
Correct Answer: B
Rationale: A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device.
The nurse is mentoring a new graduate nurse and the two are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. Which complication(s) would the nurse identify for the new nurse? Select all that apply.
- A. Absence of secretions
- B. Aspiration
- C. Infection
- D. Injury to the laryngeal nerve
- E. Penetration of the anterior tracheal wall
Correct Answer: B,C,D
Rationale: The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall.
A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first?
- A. Call for the registered nurse to reinsert the tube.
- B. Place a dilator in the stoma to maintain the opening.
- C. Cover the tracheostomy site with a sterile gauze to prevent infection.
- D. Transfer the client to the emergency department.
Correct Answer: B
Rationale: If the tracheostomy tube becomes dislodged, a dilator is initially placed to hold the edges of the stoma apart until a physician is able to reinsert the tube. A tracheal tube must never be forced back into place. Covering the tracheostomy sitewith gauze can obstruct the stoma, decreasing ventilation. If needed, transporting the client to the emergency department may occur but not until the airway is stabilized.