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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Monitor the client for adequate urine output.
When administering potassium chloride via IV infusion to a client who has severe hypokalemia, it is important for the nurse to monitor the client’s urine output to ensure that their kidneys are functioning properly and that they are able to excrete excess potassium.
Choice A is incorrect because the infusion site should be checked more frequently than every 4 hours.
Choice B is incorrect because the maximum recommended rate of infusion for potassium chloride is 10 mEq/hr.
Choice C is incorrect because Chvostek’s sign is used to assess for hypocalcemia, not hypokalemia.

A. "You will receive a general anesthetic during the procedure.". B. "You should plan to remain in bed for 18 hours after the procedure.". C. "You should expect a warm sensation after the injection of the contrast dye during the procedure.". D. "You will have blood pressure measurements every 5 minutes for the first 2 hours after the procedure.".

Correct Answer is C

Explanation

“You should expect a warm sensation after the injection of the contrast dye during the procedure.” During cardiac catheterization, a contrast dye is injected into the body to highlight blood flow through the arteries and show blockages in the blood vessels that lead to the heart.
This can cause a warm sensation.
Choice A is incorrect because usually, patients are awake during cardiac catheterization but are given medications to help them relax.
Choice B is incorrect because recovery time for a cardiac catheterization is quick.
Choice D is incorrect because there is no information found to support this statement.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering potassium chloride via IV infusion to a client who has severe hypokalemia. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is providing preoperative teaching for a client who is having a left-sided cardiac catheterization. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

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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?