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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
To calculate the amount of mL to administer, the nurse should use the following formula:
(mg ordered / mg available) x mL available = mL to administer
Substituting the values from the question, the nurse should do the following:
(100 mg / 250 mg) x 2 mL = 0.8 mL
Correct Answer is D
Explanation
Answer: D. Cheyne-Stokes respirations
Rationale:
A) Stridor: Stridor is a high-pitched, wheezing sound resulting from disrupted airflow in the upper airway. It is not characterized by alternating periods of hyperventilation and apnea, making this choice incorrect.
B) Kussmaul respirations: Kussmaul respirations are deep, labored breaths typically associated with metabolic acidosis, such as diabetic ketoacidosis. These respirations do not exhibit alternating periods of hyperventilation and apnea, so this option is not applicable.
C) Apneustic respirations: Apneustic respirations are characterized by prolonged inhalation followed by a prolonged pause before exhalation. This pattern does not align with the alternating hyperventilation and apnea described, making it an incorrect choice.
D) Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by a cyclical pattern of increasing depth and rate of breathing followed by a gradual decrease in depth and a period of apnea. This description matches the client's breathing pattern of alternating hyperventilation and apnea, making this the correct answer.
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