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

Explain the techniques of esophageal speech.

Schedule a support session for the client.

Determine the client's reading ability.

Review the use of an artificial larynx with the client.

Answer and Explanation

The Correct Answer is D

A. Explain the techniques of esophageal speech. Although teaching esophageal speech is important, the use of an artificial larynx may be more immediately relevant and easier for the client to learn and use right after surgery.

B. Schedule a support session for the client. While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.

C. Determine the client's reading ability. This may be relevant for assessing the client's ability to understand written instructions, but it is not as directly related to their immediate post-operative needs for communication.

D. Review the use of an artificial larynx with the client. This intervention is the priority because the client will need to know how to use an artificial larynx to facilitate communication after losing their natural voice. This understanding is critical for the client’s post-operative adjustment and ability to express themselves.

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Correct Answer is A

Explanation

The correct answer is that the client should press the inner corner of their eye after inserting the drops. This technique is called punctal occlusion and it helps to prevent the eye drops from draining into the tear duct and being absorbed by the rest of the body. This can increase the eﬀectiveness of the eye drops and reduce potential side eﬀects.

Options b, c and d are not correct statements by the client that indicate an understanding of how to self- administer an ophthalmic solution. Raising the eyelid up while looking down to insert the drops, keeping eyes closed for 5 minutes after inserting the drops and inserting the drops in the center of each eye are not recommended techniques for self-administering an ophthalmic solution.

A. Age B. Room number C. Photograph D. Bed number

Correct Answer is C

Explanation

A.Age alone is not a reliable or unique identifier. Many clients can share the same age, and this information does not sufficiently confirm an individual’s identity. Using age alone could lead to errors, as it lacks specificity.

B.Room numbers are not reliable for client identification because clients may be moved to different rooms or share rooms with others. Using a room number alone could easily lead to a medication error, as it does not confirm the client’s personal identity.

C.Using a photograph is an acceptable form of client identification, especially in settings where clients may not be able to verbally confirm their identity (e.g., clients with dementia). Photographs, when available, are typically included in the client’s medical records and can help ensure correct patient identification to prevent medication errors.

D.Bed numbers, similar to room numbers, are not unique to an individual and may change or be shared in multi-bed rooms. Relying on a bed number could result in giving medication to the wrong client, which is a significant risk to client safety.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is to self-administer an ophthalmic solution. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is preparing to administer a medication to a client. Which of the following should the nurse use as a client identifier?

Correct Answer is C

Explanation

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