A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make?
"Tuck your chin when you swallow so you won't choke."
"You should have no trouble swallowing fluids."
"I will add a thickener to your liquids to prevent aspiration."
"It is no longer possible for you to choke on or aspirate food."
The Correct Answer is C
A. Tucking the chin when swallowing can help reduce the risk of aspiration in clients with certain conditions, but after a total laryngectomy, clients are at increased risk for aspiration due to altered anatomy and should have thickened liquids to minimize this risk.
B. Clients who have undergone a total laryngectomy may have difficulties with swallowing and are at risk of aspiration. It is not accurate to say they will have no trouble swallowing fluids without proper assessment and adaptation.
C. Adding a thickener to liquids is a recommended intervention to reduce the risk of aspiration in clients who have had a laryngectomy, as thickened fluids are less likely to be aspirated into the lungs compared to thin liquids.
D. Clients who have had a total laryngectomy are still at risk for choking or aspiration due to changes in their swallowing mechanics and altered anatomy. It is important to take preventive measures, such as thickening liquids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Tachycardia is not a classic indicator of increased ICP. Increased ICP is more commonly associated with bradycardia or changes in heart rate patterns.
B. Restlessness can be an early sign of increased ICP, as it often reflects changes in brain function and consciousness. This should be monitored closely in a client with a traumatic brain injury.
C. Hypotension is not typically associated with increased ICP; in fact, elevated blood pressure is more commonly seen in cases of increased ICP.
D. Amnesia, while it may be related to brain injury, is not a direct sign of increased ICP. The more direct indicators are changes in level of consciousness, restlessness, and altered vital signs.
Correct Answer is C
Explanation
A. Verbalizing steps is important for understanding but does not demonstrate the ability to perform the procedure.
B. Attending a class is beneficial for learning, but it does not confirm the partner’s practical competence.
C. Performing the procedure independently indicates that the partner can effectively manage suctioning without supervision, demonstrating readiness for discharge.
D. Asking questions is a sign of engagement but does not show practical readiness.
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