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","D","E"]
Explanation
“Influenza,” and “Herpes zoster.” These statements indicate an understanding of the teaching because these immunizations are recommended for healthy adults after age 60.
Choice B is incorrect because the meningococcal vaccine is not typically recommended for healthy adults after age 60.
Choice C is incorrect because the human papillomavirus (HPV) vaccine is not typically recommended for healthy adults after age 60.
Correct Answer is C
Explanation
The nurse should plan to notify the Rapid Response Team first.
The client’s blood pressure is elevated, heart rate is high, respiratory rate is high, and oxygen saturation is low.
These are all signs of potential instability and the Rapid Response Team should be notified immediately.
Choice A is incorrect because while obtaining an ECG may be important, it is not the nurse’s first priority in this situation.
Choice B is incorrect because while calculating the extent of burns using the rule of nines may be important, it is not the nurse’s first priority in this situation.
Choice D is incorrect because while initiating peripheral IV access may be important, it is not the nurse’s first priority in this situation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.