A nurse is caring for a patient who has just undergone a laryngectomy. What action should the nurse take in this situation?
Position the head of the patient’s bed flat.
Provide the patient with humidified air.
Clean the patient’s sutures every 8 hours.
Suction the patient’s mouth on the side of the surgery.
The Correct Answer is B
Choice A rationale
Positioning the head of the patient’s bed flat is not typically recommended after a laryngectomy. Instead, the head of the bed is often elevated to help reduce swelling and improve breathing.
Choice B rationale
Providing the patient with humidified air can help keep the airway moist and reduce discomfort, making it a common practice after a laryngectomy.
Choice C rationale
While keeping the surgical site clean is important, cleaning the patient’s sutures every 8 hours is not a standard recommendation and may vary based on the surgeon’s instructions.
Choice D rationale
Suctioning the patient’s mouth on the side of the surgery is not typically recommended as it could potentially disrupt the surgical site.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Padding the mattress in a baby’s crib can pose a suffocation risk and is not recommended for crib safety22.
Choice B rationale
Placing a baby on their stomach for sleep, known as prone sleeping, increases the risk of sudden infant death syndrome (SIDS). Babies should always be placed on their back to sleep22.
Choice C rationale
Removing extra blankets from a baby’s crib is a key part of crib safety. Loose bedding can pose a suffocation risk22.
Choice D rationale
Placing a baby’s crib next to a heater could lead to overheating, which is a risk factor for SIDS. It’s important to keep the baby’s sleep environment at a comfortable temperature22.
Correct Answer is A
Explanation
Choice A rationale
The patient’s blood pressure is significantly low, which could indicate hypotension, a serious side effect of epidural analgesia. This should be the nurse’s priority as it can lead to complications such as decreased perfusion to vital organs.
Choice B rationale
Lower extremity weakness can be a side effect of epidural analgesia, but it is not as immediately life-threatening as hypotension.
Choice C rationale
A slight increase in temperature may not be an immediate concern unless it continues to rise or is accompanied by other signs of infection.
Choice D rationale
Severe itching can be a side effect of epidural analgesia, but it is not as immediately life- threatening as hypotension.
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