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 ["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

A. "Use a bronchodilator 1 hour before eating." B. "Eat 3 large meals each day." C. "Limit water intake with meals." D. "Reduce protein intake." E. None F. None

Correct Answer is A

Explanation

Using a bronchodilator 1 hour before eating can help reduce dyspnea and improve appetite for a client who has COPD. It can also facilitate oxygen delivery to the tissues and prevent hypoxia.

b) Eating 3 large meals each day is not recommended for a client who has COPD, as it can cause abdominal distension and increase pressure on the diaphragm, leading to dyspnea and fatigue. A better option is to eat 5 to 6 small meals throughout the day.
c) Limiting water intake with meals is not advisable for a client who has COPD, as it can cause dehydration and increase the viscosity of secretions, making them harder to expectorate. A better option is to drink at least 2 L of ﬂuids per day, preferably between meals.
d) Reducing protein intake is not beneficial for a client who has COPD, as protein is essential for maintaining muscle mass and strength, especially of the respiratory muscles. A better option is to increase protein intake to at least 1.2 g/kg of body weight per day.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer hydrocortisone 100 mg IM daily to a client. Available is hydrocortisone 250 mg/2 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.8"]

Explanation

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Correct Answer is A

Explanation

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