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 ["A","B","C","F","G"]
Explanation
A. Temperature: The client has a fever (39.3°C/102.8°F) indicating a potential infection or inflammatory process. This requires immediate follow-up to address the underlying cause of the fever.
B. Blood pressure: The client’s blood pressure is low (84/58 mm Hg on admission and 88/58 mm Hg current), suggesting possible shock or severe dehydration. This finding requires immediate assessment and intervention.
C. Pain level: The client reports increasing back and suprapubic pain, which could be related to a urinary tract infection or other serious condition. Addressing pain and its cause is critical.
D. Adalimumab frequency: The current medication schedule for Adalimumab is less urgent compared to the acute findings. The frequency of this medication does not require immediate follow-up in this context.
E. Heart sounds: No dysrhythmias were noted on the cardiac monitor, so this finding does not require immediate follow-up at this time.
F. WBC count: The WBC count is elevated with leucocyte esterase positive, indicating an infection. This warrants immediate attention to diagnose and treat the infection.
G. Urinalysis: The urinalysis shows cloudy appearance, foul odor, and alkaline pH with positive leucocyte esterase, suggesting a urinary tract infection. This requires immediate follow-up to start appropriate treatment.
H. Hgb & Hct: While important, these values are not provided in the current context. The immediate concerns are more focused on the acute symptoms and signs provided.
Correct Answer is D
Explanation
A. Protein restriction is not universally indicated; specific dietary changes depend on the type of stones.
B. Ambulation is often encouraged to help pass stones and alleviate discomfort.
C. Applying cold compresses can be helpful for pain relief, but fluid intake is more critical for managing urolithiasis.
D. Increasing fluid intake to at least 3 L per day helps flush out stones and prevent new ones from forming.
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