A nurse is caring for a client who has just undergone a total laryngectomy.
Which of the following findings is the nurse's priority for immediate intervention?
Fever.
Blood-tinged secretions.
Tachypnea.
IV infiltration.
The Correct Answer is C
The nurse’s priority for immediate intervention is tachypnea, which is rapid breathing.
Tachypnea can be a sign of respiratory distress and requires immediate intervention.
Choice A is wrong because while a fever may indicate an infection, it is not the priority for immediate intervention.
Choice B is wrong because while blood-tinged secretions may indicate bleeding, it is not the priority for immediate intervention.
Choice D is wrong because while IV infiltration may cause discomfort and require attention, it is not the priority for immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse’s priority assessment in the PACU (Post-Anesthesia Care Unit) should be the client’s respiratory status.
This is because the client is recovering from anesthesia and may have an altered respiratory function.
Choice B, assessing the surgical site, is not an answer because it is not the priority assessment for a client in the PACU.
Choice C, assessing the level of consciousness, is not an answer because it is not the priority assessment for a client in the PACU.
Choice D, assessing the pain level, is not an answer because it is not the priority assessment for a client in the PACU.
Correct Answer is B
Explanation
The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first.
Thrombocytopenia is a condition characterized by low platelet count, which increases the risk of bleeding.
A nosebleed can be a sign of significant bleeding, and it is important for the nurse to assess the severity and take appropriate action to stop the bleeding and prevent further complications.
Although the other clients also require nursing care, their conditions are not as urgent as the client with thrombocytopenia and a nosebleed.
The client with chronic obstructive pulmonary disease and an oxygen saturation of 89% may require oxygen therapy or other interventions to improve respiratory function, but the situation is not immediately life-threatening.
The client with left-sided paralysis and slurred speech from a prior stroke may require ongoing care and rehabilitation, but there is no indication of an acute change in their condition.
The client with multiple sclerosis and ataxia and vertigo may require assistance with mobility and balance, but their symptoms do not pose an immediate threat to their health.
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