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 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.

A. The medication will prevent wheezing. B. The medication will decrease coughing episodes. C. The medication will reduce inﬂammation. D. The medication will open the airways. E. The medication will stimulate ﬂow of mucus.

Correct Answer is ["A","B","D"]

Explanation

Answer: A, B D

Rationale:

Albuterol is a bronchodilator, and one of its key effects is to relax the muscles around the airways, which helps prevent wheezing. Wheezing is often caused by narrowed airways, and by opening them, albuterol helps to prevent this sound, which is associated with asthma or other respiratory conditions.
B. The medication will decrease coughing episodes:
Albuterol can help decrease coughing in individuals with conditions like asthma or chronic obstructive pulmonary disease (COPD) by relaxing the muscles in the airways, which reduces airway constriction. Since coughing often occurs due to airway obstruction, albuterol’s bronchodilator effect can help alleviate this symptom.
C. The medication will reduce inflammation: Albuterol does not have anti-inflammatory properties. Its primary mechanism is bronchodilation, and anti-inflammatory treatment generally requires corticosteroids, not beta-agonists like albuterol.
D. The medication will open the airways:
This is correct. Albuterol works as a bronchodilator, meaning it opens up the airways by relaxing the smooth muscles surrounding them. This improves airflow and makes breathing easier, which is why it is often used in conditions like asthma or COPD.
E. The medication will stimulate flow of mucus: Albuterol does not stimulate mucus production; it primarily works by relaxing the airways. However, by improving airflow, it can help clients more effectively expel mucus through coughing.

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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 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

A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is preparing to titrate morphine 6 mg via IV bolus to a client. The amount available is morphine 8 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

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