A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client's care?

Patency of the intravenous line.

Need for suctioning.

Integrity of the dressing.

Level of pain.

Answer and Explanation

The Correct Answer is B

Suctioning is the priority observation in the client's care, as it prevents airway obstruction and respiratory distress caused by blood, mucus, or secretions. The client has a permanent tracheostomy and cannot cough or clear the airway eﬀectively. The nurse should assess the need for suctioning frequently and perform it as needed, using sterile technique and maintaining oxygenation.

a) Patency of the intravenous line is important, but not the priority observation in the client's care. The intravenous line provides ﬂuids, electrolytes, and medications to the client, but it does not aﬀect the airway patency or oxygenation.
c) Integrity of the dressing is important, but not the priority observation in the client's care. The dressing protects the surgical site from infection and bleeding, but it does not aﬀect the airway patency or oxygenation.
d) Level of pain is important, but not the priority observation in the client's care. The pain can be managed with analgesics and nonpharmacological measures, but it does not aﬀect the airway patency or oxygenation.

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Correct Answer is C

Explanation

Agitation is a sign of hypoxemia, as the brain is deprived of oxygen and becomes irritable and restless.

The other options are not correct because:

Nausea is not a specific manifestation of hypoxemia, as it can have many other causes such as medication side eﬀects, gastrointestinal disorders, or anxiety.
Dysphagia is difficulty swallowing, which is not related to hypoxemia or asthma. It can be caused by neurological, muscular, or structural problems in the throat or esophagus.
Hypotension is low blood pressure, which is not a typical manifestation of hypoxemia or asthma. It can be caused by dehydration, blood loss, shock, or heart failure.

A. Determine the cause of the acute exacerbation. B. Obtain a peak ﬂow reading. C. Administer an inhaled glucocorticoid. D. Administer a short-acting beta2-agonist (SABA).

Correct Answer is D

Explanation

Administering a short-acting beta2-agonist (SABA), such as albuterol, is the priority intervention for the nurse to take, as it provides rapid bronchodilation and relieves bronchospasm, which are the main features of status asthmaticus. Status asthmaticus is a severe and life-threatening asthma attack that does not respond to usual treatment and requires immediate medical attention.

a) Determining the cause of the acute exacerbation is important, but not the priority intervention for the nurse to take. The cause may be an allergen, infection, stress, or exercise, but it does not aﬀect the immediate management of status asthmaticus. The nurse should focus on restoring airway patency and oxygenation first, and then identify and avoid triggers later.
b) Obtaining a peak ﬂow reading is important, but not the priority intervention for the nurse to take. The peak ﬂow reading measures the maximum expiratory ﬂow rate and indicates the degree of airway obstruction. However, it may not be feasible or accurate in a child who is experiencing status asthmaticus, as they may be too dyspneic or agitated to perform the test. The nurse should rely on other signs of respiratory distress, such as wheezes, retractions, cyanosis, or pulse oximetry.
c) Administering an inhaled glucocorticoid is important, but not the priority intervention for the nurse to take. Glucocorticoids, such as ﬂuticasone or budesonide, reduce inﬂammation and mucus production in the airways, but they have a delayed onset of action and are not eﬀective for acute asthma attacks. They are used for long-term control and prevention of asthma symptoms.

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A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client's care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take?

Correct Answer is D

Explanation

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