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 C

Explanation

The nurse should include this intervention in the plan of care because it can help relieve pressure on the reddened areas over the client’s bony prominences and prevent the development of pressure injuries.
Choice A is incorrect because applying an occlusive dressing to intact skin over bony prominences is not an appropriate intervention for preventing pressure injuries.
Choice B is incorrect because turning and repositioning the client every 4 hours may not be frequent enough to prevent the development of pressure injuries.
The client should be turned and repositioned more frequently, at least every 2 hours.
Choice D is incorrect because massaging reddened areas over bony prominences is not recommended as it can cause further damage to the skin and underlying tissues.

A. Increased cardiac output. B. Pleural effusion. C. Fluid volume excess. D. Aspiration.

Correct Answer is C

Explanation

“Fluid volume excess.” Bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning are all signs of fluid volume excess.
Fluid volume excess can occur when the heart is unable to pump blood efficiently, causing fluid to build up in the lungs.
Choice A is not the correct answer because the increased cardiac output would not cause these symptoms.
Choice B is not the correct answer because pleural effusion refers to a buildup of fluid between the layers of tissue that line the lungs and chest cavity, which would not cause these symptoms.
Choice D is not the correct answer because aspiration refers to the inhalation of food, liquid, or other substances into the lungs, which would not cause these symptoms.

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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 completing an assessment of an older adult client and notes reddened areas over the bony prominences, but the client's skin is intact. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is caring for a client who has bounding pulses, crackles on auscultation, and pink frothy secretions when receiving suctioning. The nurse should recognize these assessment findings as indicating which of the following?

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?