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.

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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Correct Answer is B

Explanation

Crackles in the lungs indicate that the client is experiencing ﬂuid overload. When there is an excess of ﬂuid in the body, it can accumulate in the lungs and cause crackles. The other

a. Fever is not a sign of ﬂuid overload.

c. Bradycardia (a slow heart rate) is not a sign of ﬂuid overload.

d. Flattened neck veins are not a sign of ﬂuid overload; distended neck veins may be a sign of ﬂuid overload.

A. The client stoops slightly forward when moving the walker. B. The client moves the walker ahead 25.4 cm (10 in) with each step. C. The client stands with her elbows slightly ﬂexed while holding the walker. D. The client picks up the walker with each step.

Correct Answer is C

Explanation

When using a two-wheeled walker, the client should stand with their elbows slightly ﬂexed while holding the walker. This allows for proper posture and support while using the walker.

Option a is incorrect because stooping forward can cause strain on the back and neck.

Option b is incorrect because moving the walker too far ahead can cause instability and increase the risk of falls.

Option d is incorrect because picking up the walker with each step can cause fatigue and decrease the eﬀectiveness of the walker.

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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

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