A nurse is caring for a patient who is 9 days postoperative following a total laryngectomy. The nurse removes the patient’s NG tube and initiates oral feedings.
Which of the following statements should the nurse make?
“You should have no trouble swallowing fluids.”.
“It is no longer possible for you to choke on or aspirate food.”.
“I will add a thickener to your liquids to prevent aspiration.”.
“Tuck your chin when you swallow so you won’t choke.”.
The Correct Answer is D
Choice A rationale
After a total laryngectomy, patients may have difficulty swallowing fluids due to changes in the anatomy of the throat.
Choice B rationale
It is not accurate to say that it is no longer possible for the patient to choke on or aspirate food after a total laryngectomy. While the risk of aspiration is reduced because the airway and digestive tract are separated, the patient can still experience choking on food if it is not properly swallowed.
Choice C rationale
Adding a thickener to liquids can help prevent aspiration, but this is typically more relevant for patients with dysphagia or other swallowing disorders, not specifically for patients post- laryngectomy.
Choice D rationale
Tucking the chin when swallowing, also known as the chin-tuck maneuver, can help prevent aspiration by narrowing the entrance to the airway. This can be a useful technique for patients after a laryngectomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Providing a list of the client’s current medications during the change of shift report is not a part of medication reconciliation. While it is important to communicate about a patient’s medications during shift changes, medication reconciliation is a more comprehensive process that involves comparing the medications a patient is taking with newly ordered medications.
Choice B rationale
Over-the-counter medications should be included in the medication reconciliation report. Over-the-counter medications can interact with prescription medications and affect a patient’s health, so it’s important to include them in medication reconciliation.
Choice C rationale
Medication reconciliation should be performed for a client at discharge from a health care facility. This is a critical step in ensuring the patient continues to take the correct medications at home.
Choice D rationale
Providing a list of the client’s current medications during admission to a health care facility is a part of medication reconciliation. This helps to ensure that the patient’s medications are correctly managed during their stay in the facility.
Correct Answer is ["120"]
Explanation
The correct answer is 120 gtt/min.
Step 1 is to convert the infusion rate from mL/hr to mL/min: 120 mL/hr ÷ 60 min/hr = 2 mL/min.
Step 2 is to multiply the mL/min rate by the drop factor to find the gtt/min rate: 2 mL/min × 60 gtt/mL = 120 gtt/min.
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