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?

A. While tissue integrity is important, the primary concern immediately postoperatively for a patient who has undergone a partial laryngectomy is ensuring that the airway is open and clear.
B. Airway patency should be assessed first because this surgery involves the upper airway structures, and complications such as obstruction, swelling, or bleeding could compromise the airway and lead to respiratory distress.
C. Pain severity should be assessed as part of routine care, but airway patency takes precedence to prevent respiratory complications.
D. Wound drainage should be monitored but does not take priority over airway assessment in the immediate postoperative period.

A. Obtain a prescription for supplemental oxygen: This is the correct answer. The patient is experiencing hypoxia, and ensuring adequate oxygenation is the priority. Oxygen supplementation is essential to correct the hypoxia, which can exacerbate metabolic disturbances like diabetic ketoacidosis (DKA). Improving oxygenation will also support other treatments, such as insulin administration, by improving tissue perfusion.
B. Obtain a prescription to administer insulin: While insulin is a key treatment for DKA, addressing hypoxia first is more urgent. Hypoxia can impair the effectiveness of insulin and other therapies, so stabilizing the patient’s oxygen levels should be prioritized before insulin administration.
C. Obtain a prescription to administer intravenous fluids: Administering fluids is important in DKA management, especially for rehydration and correcting electrolyte imbalances. However, addressing hypoxia first is the priority to stabilize the patient and ensure optimal perfusion for further interventions like fluid resuscitation.
D. Obtain a prescription to check the client's glucose level: This is not necessary, as the glucose level is likely already elevated, which is characteristic of DKA. The focus should be on stabilizing the patient's airway and oxygenation before monitoring glucose levels or starting insulin.