A nurse is preparing to discharge a client who is a status post-operative laryngectomy. The nurse should recognize which of the following discharge teaching is the highest priority?
Use of Passy Muir speaking valve
Phone number of healthcare provider to report complications
Emergency personal identification that client is unable to speak
Ability to perform tracheostomy care
The Correct Answer is C
A. Use of Passy Muir speaking valve: While this is an important aspect of communication for a client who has undergone a laryngectomy, it is not the highest priority at the time of discharge. The use of the speaking valve can be addressed after ensuring that the client is equipped to handle immediate safety concerns and emergencies related to their condition.
B. Phone number of healthcare provider to report complications: Providing the client with contact information for their healthcare provider is essential for ongoing support and to address any concerns that may arise after discharge. However, this information is secondary to ensuring the client can effectively communicate their condition and limitations, particularly in an emergency situation.
C. Emergency personal identification that client is unable to speak: This is the highest priority for discharge teaching because it directly addresses the client’s safety. Having emergency identification is crucial for informing healthcare providers and first responders about the client's inability to speak, especially in situations where communication may be vital for receiving appropriate care. Ensuring that the client can communicate their condition in emergencies takes precedence over other aspects of post-operative care.
D. Ability to perform tracheostomy care: While it is important for the client to be educated on tracheostomy care to ensure ongoing health and safety, this teaching can be considered after addressing immediate safety needs. The ability to care for the tracheostomy is vital but does not take priority over having emergency identification that communicates the client’s needs to others who may not be aware of their condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encourage the client to take breaks from oxygen use to prevent tolerance. Oxygen therapy does not cause "tolerance," and taking breaks can lead to hypoxemia in COPD clients. Continuous low-flow oxygen is essential to maintaining adequate oxygenation while avoiding hypercapnia. Stopping oxygen therapy intermittently can increase the risk of respiratory distress.
B. Assess cheeks and posterior ears for signs of skin breakdown. While it is important to monitor for pressure injuries from nasal cannula tubing, this is a general nursing consideration for all patients receiving oxygen therapy. It is not the highest priority when managing oxygen therapy in clients with COPD, where maintaining appropriate oxygen levels is critical.
C. Maintain nasal oxygen at a 1 to 2 liter/minute flow rate. Clients with COPD often have chronic CO₂ retention and rely on hypoxic drive for ventilation. Administering high-flow oxygen can suppress their respiratory drive, leading to CO₂ narcosis and respiratory failure. To prevent this, oxygen should be administered at the lowest effective flow rate, typically 1 to 2 L/min via nasal cannula, while closely monitoring oxygen saturation and blood gases.
D. Teach the client how to safely increase oxygen flow when they deem necessary. Allowing a client with COPD to adjust their oxygen flow independently can be dangerous, as excessive oxygen can lead to hypercapnia and respiratory depression. Oxygen adjustments should be made based on clinical assessments and healthcare provider orders.
Correct Answer is A
Explanation
A. Opening and utilizing supplies that are necessary for the task. The efficiency domain in healthcare quality focuses on minimizing waste, optimizing resource utilization, and reducing unnecessary costs. By ensuring that only necessary supplies are used, healthcare facilities can prevent waste, control expenses, and enhance operational efficiency, making this choice the best representation of the efficiency domain.
B. Working to reduce wait times in the emergency department. Reducing wait times falls under the timeliness domain rather than efficiency. Timeliness ensures that patients receive care without unnecessary delays, improving access to treatment and patient outcomes. While efficiency and timeliness are related, reducing wait times primarily aligns with improving prompt care delivery rather than minimizing waste.
C. Using an interpreter for patients who do not speak the health-care provider's language. This action falls under the equity domain, which ensures that all individuals receive fair and unbiased care regardless of language, socioeconomic status, or cultural background. Providing language services improves access to quality healthcare but does not specifically address efficiency.
D. Utilizing the CAUTI bundle to prevent urinary tract infections when placing indwelling urinary catheters. This initiative falls under the safety domain, which focuses on preventing harm to patients through evidence-based practices. Implementing infection prevention measures improves patient safety but is not directly related to efficiency, which focuses on cost-effectiveness and resource management.
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