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
Agitation is a sign of hypoxemia, as the brain is deprived of oxygen and becomes irritable and restless.
The other options are not correct because:
- Nausea is not a specific manifestation of hypoxemia, as it can have many other causes such as medication side effects, gastrointestinal disorders, or anxiety.
- Dysphagia is difficulty swallowing, which is not related to hypoxemia or asthma. It can be caused by neurological, muscular, or structural problems in the throat or esophagus.
- Hypotension is low blood pressure, which is not a typical manifestation of hypoxemia or asthma. It can be caused by dehydration, blood loss, shock, or heart failure.
Correct Answer is A
Explanation
Montelukast is an oral leukotriene receptor antagonist that prevents inflammation and bronchoconstriction in asthma. It is taken once daily in the evening to prevent nocturnal symptoms and improve morning lung function.
- "I rinse my mouth after taking this medication." This is not necessary, as montelukast is not associated with oral thrush or dysgeusia, unlike some inhaled corticosteroids.
- "I use a spacer device when I inhale this medication." This is not applicable, as montelukast is not an inhaler, but a tablet or chewable form.
- "I take this medication when I get an asthma attack." This is not appropriate, as montelukast is not a rescue medication, but a maintenance medication that should be taken regularly to prevent asthma exacerbations. A short-acting beta2 agonist such as albuterol should be used for acute relief of symptoms.
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