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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cerebral edema is the most dangerous complication associated with the administration of hypotonic fluids in patients with diabetic ketoacidosis (DKA). This occurs because hypotonic fluids cause rapid shifts in fluid and electrolytes, which can lead to swelling of the brain, especially in children. The risk is heightened if fluids are replaced too quickly.
B. Polyuria is a common symptom of diabetic ketoacidosis due to high blood glucose levels and osmotic diuresis, but it is not caused by hypotonic fluid administration.
C. Hypokalemia is a potential risk in DKA but typically arises from the shift of potassium from the extracellular to intracellular space during treatment, especially with insulin administration, not from the use of hypotonic fluids.
D. Metabolic acidosis is a hallmark of diabetic ketoacidosis itself and is caused by the accumulation of ketones. It is not caused by hypotonic fluid replacement.
Correct Answer is ["A","C","D","E"]
Explanation
A. Purple striations: This is correct. One of the characteristic manifestations of Cushing's syndrome is the development of purple or reddish stretch marks (striae) on the skin, which are caused by the weakening of the skin due to excessive cortisol.
B. Tremors: This is not typically a manifestation of Cushing's syndrome. Tremors are more commonly seen in conditions such as hyperthyroidism or neurological disorders, not in Cushing's syndrome.
C. Hypertension: This is correct. Elevated cortisol levels in Cushing's syndrome can lead to fluid retention, sodium retention, and increased blood pressure, resulting in hypertension.
D. Buffalo hump: This is correct. A buffalo hump, or a fatty accumulation on the upper back and neck, is a common feature of Cushing's syndrome. It is caused by the redistribution of fat due to elevated cortisol levels.
E. Moon face: This is correct. "Moon face" refers to the round, puffy face that is a hallmark sign of Cushing's syndrome. The face becomes swollen due to fat accumulation, a result of high cortisol levels.
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