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 C

Explanation

When caring for an immunocompromised client, the nurse should prioritize infection prevention and control measures. One essential action is to cleanse hands with an alcohol-based hand rub before client contact. Hand hygiene is crucial in reducing the transmission of microorganisms and preventing infections. Using an alcohol-based hand rub is eﬀective in killing many types of germs, including bacteria and viruses.

Let's now discuss why the other

Options are not the correct answers:

a. Place the client in a semiprivate room: Placing the client in a semiprivate room increases the risk of exposure to potential infections from other individuals. Immunocompromised clients have a weakened immune system, making them more susceptible to infections. Therefore, it is recommended to provide them with a private room to minimize the risk of exposure to pathogens.

b. Have the client apply a mask when children are visiting: While it is generally important to take precautions when visitors are present, having the client wear a mask when children are visiting may not be sufficient to protect the immunocompromised client. Children can carry and transmit various infectious diseases, even without displaying symptoms. Therefore, it is more appropriate for healthcare providers and visitors, including children, to adhere to strict hand hygiene and other infection control measures to minimize the risk of infection transmission.

d. Use sterile gloves to provide perineal care: The use of sterile gloves is not necessary for routine perineal care unless there is a specific indication, such as an open wound or surgical site. For routine perineal care, clean, non-sterile gloves are sufficient. Using sterile gloves unnecessarily can contribute to the development of antimicrobial resistance and increase healthcare costs without providing any additional benefits.

In summary, when caring for an immunocompromised client, the nurse should prioritize infection prevention and control. Cleansing hands with an alcohol-based hand rub before client contact is an important action to reduce the risk of infection transmission. The other

Options, such as placing the client in a semiprivate room, having the client wear a mask when children are visiting, and using sterile gloves for routine perineal care, are not the appropriate actions in this scenario.

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

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