A nurse is providing care for a client who is scheduled for a total laryngectomy. Which of the following is the nurse's priority intervention?

Show the client how to use an artificial larynx.

Arrange a support session for the client.

Demonstrate the use of esophageal speech.

Determine the client's reading ability.

Answer and Explanation

The Correct Answer is D

A.   Showing the client how to use an artificial larynx is an important aspect of post-laryngectomy care, but determining the client's reading ability takes precedence as it will significantly impact communication options.
B.   Arranging a support session is important for emotional support, but assessing the client's reading ability is more immediate in addressing communication needs.
C.   Demonstrating the use of esophageal speech is relevant, but understanding the client's reading ability is a priority before exploring communication alternatives.

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Correct Answer is C

Explanation

A. Choosing a vein that is soft on palpation may indicate it's not suitable for IV insertion. A vein with a slight bounce or resilience is preferable.
B. Selecting a vein in the client's dominant arm is not a primary consideration. Both arms are

usually suitable, and the choice depends on factors such as accessibility and patient preference.

C. Selecting a site distal to previous venipuncture attempts reduces the risk of complications such as infiltration or infection and allows for optimal vein preservation.
D. Choosing the most proximal vein in the extremity is not typically recommended for peripheral IV insertion. Veins more distal to the body are often preferred for initial attempts, with
consideration for vein integrity and accessibility.

A. Open the first flap of the sterile kit toward himself. B. Ensure that the sterile field is located below waist level. C. Place dry, sterile supplies 1/2 inch from the edge of the sterile field. D. Apply sterile gloves after preparing the sterile field.

Correct Answer is C

Explanation

A. Opening the first flap of the sterile kit away from the body helps maintain the sterility of the contents.
B. The sterile field should be above waist level to avoid contamination.

C. Placing dry, sterile supplies 1/2 inch from the edge of the sterile field helps prevent contamination of the items.
D. Sterile gloves should be donned before preparing the sterile field to avoid contamination.

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A nurse is providing care for a client who is scheduled for a total laryngectomy. Which of the following is the nurse's priority intervention?

Nursing Test Bank

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