Nokea
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.
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What complication can result from tracheal suctioning?
- A. Acute hypoxemia
- B. Gastric dilatation
- C. Hypervolemic shock
- D. Epiglottitis
Correct Answer: A
Rationale: Suctioning temporarily reduces oxygen levels, necessitating careful monitoring.
What volume of fluid loss causes marked deterioration in hypovolemic shock?
- A. 30% to 40% (1500 mL to 2000 mL)
- B. 15% to 30% (750 mL to 1500 mL)
- C. 10% to 15% (500 mL to 750 mL)
- D. More than 40% (more than 2000 mL)
Correct Answer: B
Rationale: Loss of 15% to 30% of blood volume significantly impairs circulation and tissue perfusion.
Priority Decision: A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient?
- A. Hypoxemia
- B. Neurologic injury
- C. Distended bladder
- D. Cardiac dysrhythmias
Correct Answer: A
Rationale: Hypoxemia is a common cause of agitation and delirium during emergence from anesthesia.
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.
What observation would indicate the water-seal drainage system is working correctly?
- A. No bubbling of air in the suction control bottle
- B. Fluctuation of the fluid level in the tube of the water-seal bottle
- C. 25 ml of serosanguineous fluid has collected in the drainage bottle
- D. Excessive bubbling in the water-seal bottle
Correct Answer: B
Rationale: Fluctuation indicates proper lung expansion and absence of leaks.