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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?

A.

Explain the techniques of esophageal speech.

B.

Schedule a support session for the client.

C.

Determine the client's reading ability.

D.

Review the use of an artificial larynx with the client.

E.

None

F.

None

Answer and Explanation

The Correct Answer is C

A. Explain the techniques of esophageal speech. Esophageal speech is one method of communication but is learned later through speech therapy. Not the immediate priority.

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. After surgery, the client will not be able to speak initially. Knowing if the client can read and write allows the nurse to provide a communication method (such as writing or using a communication board) to meet immediate needs, especially related to airway, pain, and care.

D. Review the use of an artificial larynx with the client. An electrolarynx is an option but is introduced later in recovery. It is not the immediate concern before surgery.

 


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Related Questions

Correct Answer is D

Explanation

The correct answer is choice d. Begin by testing the client while they are wearing glasses. Choice A rationale: Positioning the client 3.3 meters (10 feet) away from the chart is incorrect because the standard distance for the Snellen chart is 20 feet (6 meters). Choice B rationale: Documenting the largest line the client can read on the chart is part of the procedure, but it is not the initial action the nurse should take. The nurse must first ensure the client is wearing their glasses to get an accurate assessment. Choice C rationale: Instructing the client to begin the assessment with both eyes open is incorrect because visual acuity is typically tested one eye at a time, with the other eye covered. Choice D rationale: Beginning by testing the client while they are wearing glasses is correct because it provides the most accurate assessment of the client’s visual acuity in their usual state, ensuring the glasses are effectively correcting their vision​

Correct Answer is B

Explanation

Before administering enteral feedings via an NG tube, the nurse should check for gastric residual volume to ensure that the client is able to tolerate the feeding. If the residual volume is high, it may indicate delayed gastric emptying and the feeding may need to be delayed or the rate adjusted.

a. Encouraging the client to take sips of water may help maintain hydration, but it is not necessary prior to administering enteral feedings.

c. Flushing the tube with sterile 0.9% sodium chloride irrigation can help maintain patency of the tube, but it is not necessary prior to administering enteral feedings.

d. Encouraging the client to breathe deeply and cough can help clear secretions from the lungs, but it is not necessary prior to administering enteral feedings.

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