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 B

Explanation

A. Restrict fluid intake: This is incorrect. Clients with Addison’s disease are at risk for dehydration, especially during an Addisonian crisis. Fluids should be encouraged to help maintain blood pressure and fluid balance, rather than restricting fluid intake.
B. Administer oral corticosteroids: This is the correct action. Clients with Addison's disease have insufficient cortisol production, especially during times of stress or illness. Oral corticosteroids, such as hydrocortisone, are given to replace the deficient hormones and prevent or manage an Addisonian crisis.
C. Provide a low-carbohydrate diet: This is incorrect. Clients with Addison’s disease should have a balanced diet that includes adequate carbohydrates to support energy needs, especially during stress or illness. A low-carbohydrate diet could lead to further complications like hypoglycemia.
D. Weigh the client daily: While daily weight measurements can be helpful in monitoring for fluid retention or loss, it is not a primary intervention for preventing or managing Addisonian crisis. The most critical action is providing the necessary corticosteroid replacement therapy.

A. Moist mucous membranes B. Bounding peripheral pulses C. Urine specific gravity 1.002 D. Bradycardia

Correct Answer is C

Explanation

A. Moist mucous membranes: This is incorrect. In diabetes insipidus, the body loses large amounts of water due to a deficiency of antidiuretic hormone (ADH) or its effects. As a result, the client often experiences dehydration, leading to dry mucous membranes, not moist ones.
B. Bounding peripheral pulses: This is incorrect. While bounding pulses are often seen in conditions like fluid overload or hypervolemia, diabetes insipidus typically causes dehydration due to excessive urination, which would not lead to bounding pulses. The pulses would more likely be weak or thready due to fluid loss.
C. Urine specific gravity 1.002: This is the correct finding. In diabetes insipidus, the kidneys are unable to concentrate urine, resulting in very dilute urine. A urine specific gravity of 1.002 indicates very diluted urine, which is characteristic of diabetes insipidus.
D. Bradycardia: This is incorrect. Bradycardia (slow heart rate) is not typically associated with diabetes insipidus. In fact, tachycardia (increased heart rate) can occur as a compensatory response to dehydration caused by excessive urination in diabetes insipidus.

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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

A nurse is caring for a client who has Addison's disease and is at risk for Addisonian crisis. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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