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 B
Explanation
A. While avoiding infection is important for individuals with Addison's disease due to their weakened immune system, the priority is ensuring proper medication management.
B. Managing lifelong corticosteroid replacement is the most crucial instruction because individuals with Addison's disease have insufficient production of adrenal hormones, particularly cortisol. Without appropriate corticosteroid therapy, they can experience life-threatening adrenal crises.
C. Wearing a Medic-Alert bracelet is a helpful precaution, but it is not as immediately critical as ensuring proper medication management.
D. Practicing stress-management techniques is beneficial, as stress can exacerbate symptoms of Addison's disease, but corticosteroid replacement remains the highest priority.
Correct Answer is A
Explanation
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
