After observing blood-tinged mucous when suctioning a patient who has just arrived on the medical-surgical unit after a laryngectomy, which action by the nurse is best?

Place the patient in a lateral recovery position for better drainage of the secretions.

Activate the rapid-response team.

Keep monitoring the oxygen saturation and respiratory rate.

Increase the humidification of the patient's oxygen.

Answer and Explanation

The Correct Answer is A

A. Placing the patient in a lateral recovery position is the best immediate action. This position helps facilitate drainage of secretions, especially after a laryngectomy, which can reduce the risk of aspiration and airway obstruction. The blood-tinged mucus may be due to recent surgery and should be monitored for changes.
B. The activation of the rapid-response team may be necessary if the patient’s condition worsens or becomes critical, but there is no indication of an acute life-threatening event based on the blood-tinged mucus alone.
C. Monitoring the oxygen saturation and respiratory rate is important, but it is a secondary concern compared to providing a position that promotes drainage and prevents aspiration.
D. Increasing humidification of the oxygen may help keep the airway moist, but the immediate priority should be ensuring proper positioning to allow secretion drainage and prevent aspiration.

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Correct Answer is A

Explanation

A. After administering a carbohydrate source (e.g., 6 oz of orange juice), the nurse should reassess the patient's blood glucose level. If the glucose is still below the target range (typically above 70 mg/dL), the next step is to give an additional 15 grams of carbohydrate to raise the blood sugar. This is a standard approach for mild to moderate hypoglycemia.
B. Giving 25 to 50 ml of 50% glucose IV is typically reserved for patients who are severely hypoglycemic and unable to swallow or are unresponsive. This method is appropriate when the patient cannot take oral glucose, but the client in this scenario is still conscious.
C. Administering 1 mg IM glucagon is used when a patient is unable to ingest glucose orally and is unresponsive or vomiting. It stimulates the liver to release stored glucose, but this is not necessary in a conscious patient who can swallow.
D. Administering a 5% to 10% dextrose infusion is typically used in more severe cases of hypoglycemia, especially when IV access is established, and the patient is unable to take oral glucose. This would not be necessary for a patient who can safely swallow.

A. Increase carbohydrate intake. B. Limit intake of potassium-rich foods. C. Restrict sodium intake. D. Decrease protein intake.

Correct Answer is C

Explanation

A. Increase carbohydrate intake.: This is incorrect. Cushing’s disease is characterized by excessive cortisol, which can lead to increased blood glucose levels, making carbohydrate intake less desirable. Clients with Cushing's disease often need to manage their blood sugar levels, so they should not increase carbohydrates indiscriminately.
B. Limit intake of potassium-rich foods.: This is incorrect. In Cushing’s disease, elevated cortisol levels can lead to potassium depletion, so clients should actually increase their intake of potassium-rich foods to help counteract the effects of low potassium, not limit them.
C. Restrict sodium intake.: This is correct. Cushing’s disease often results in fluid retention and hypertension due to increased cortisol and aldosterone levels. Restricting sodium helps manage these symptoms and reduces the risk of complications such as edema and high blood pressure.
D. Decrease protein intake.: This is incorrect. While protein breakdown is a feature of Cushing's disease, protein intake should not necessarily be decreased. Adequate protein intake is important to prevent muscle wasting, a common issue in clients with Cushing’s disease.

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After observing blood-tinged mucous when suctioning a patient who has just arrived on the medical-surgical unit after a laryngectomy, which action by the nurse is best?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After giving 6 oz of orange juice to a patient with hypoglycemia, the nurse finds that the patient's blood glucose level is 65 mg/dl. Which nursing intervention would be the most appropriate in this situation?

Correct Answer is A

Explanation

A nurse is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should the nurse include in the teaching?

Correct Answer is C

Explanation

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The nurse notes that which disorder places the patient at greatest risk for hypertensive crisis?

In reviewing admission orders for a patient admitted with SIADH, the nurse should question which order?

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