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 A

Explanation

Hyperextended position, or backward bending of the neck, is the correct position for the client's neck during a bronchoscopy procedure with a rigid scope and general anesthesia. This position allows the provider to insert the scope through the mouth and into the trachea and bronchi, while avoiding injury to the teeth, tongue, or larynx. It also facilitates visualization of the airways and removal of foreign bodies or secretions.

b) Neutral position, or alignment of the head and neck with the spine, is not the correct position for the client's neck during a bronchoscopy procedure with a rigid scope and general anesthesia. This position may interfere with the insertion of the scope and cause damage to the oral structures or airways.
c) Extended position, or forward bending of the neck, is not the correct position for the client's neck during a bronchoscopy procedure with a rigid scope and general anesthesia. This position may obstruct the airway and make it difficult for the provider to insert the scope and access the bronchi.
d) Flexed position, or downward bending of the neck, is not the correct position for the client's neck during a bronchoscopy procedure with a rigid scope and general anesthesia. This position may compress the airway and prevent adequate ventilation and oxygenation of the client.

A. Administer low-ﬂow oxygen continuously via nasal cannula. B. Oﬀer high-protein and high-carbohydrate foods frequently. C. Place in a prone position. D. Encourage oral intake of at least 3,000 mL of ﬂuids per day.

Correct Answer is C

Explanation

Placing the client in a prone position improves oxygenation and ventilation by reducing lung compression, increasing lung expansion, and redistributing blood ﬂow to better match ventilation.

a) Administering low-ﬂow oxygen via nasal cannula is not sufficient for a client with ARDS, who requires
high levels of oxygenation and positive pressure ventilation to prevent alveolar collapse and hypoxemia.
b) Oﬀering high-protein and high-carbohydrate foods frequently is beneficial for a client with ARDS, as it provides adequate nutrition and energy to support lung healing and prevent muscle wasting. However, it is not the priority intervention for improving respiratory function.
d) Encouraging oral intake of at least 3,000 mL of ﬂuids per day is contraindicated for a client with ARDS, who is at risk of ﬂuid overload and pulmonary edema. Fluid intake should be restricted and diuretics should be administered as prescribed to reduce ﬂuid accumulation in the lungs.

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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 teaching a client who will undergo a bronchoscopy procedure. The provider will use a rigid scope and general anesthesia. The nurse should explain that the client's neck will be in which of the following positions?

Correct Answer is A

Explanation

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

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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?