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 C
Explanation
Increasing fluid intake helps to hydrate the mucous membranes and thin the respiratory secretions, which facilitates expectoration and improves gas exchange.
- Encourage coughing and deep breathing. This is beneficial for clearing the airways and preventing atelectasis, but it does not directly affect the viscosity of the secretions.
- Encourage regular use of the incentive spirometer. This is helpful for expanding the lungs and preventing complications such as pneumonia or pleural effusion, but it does not influence the consistency of the secretions.
- Encourage the client to ambulate frequently. This is important for promoting circulation and mobility, but it does not have a significant effect on the thinning of the secretions.
Correct Answer is B
Explanation
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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