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.
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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 B
Explanation
A. 4 oz diet soda: This is incorrect. Diet soda contains no sugar and will not raise the client's blood glucose level. Although it may provide some hydration, it won't address the hypoglycemia.
B. 4 oz skim milk: This is the correct choice. Skim milk contains both lactose (a sugar) and protein, which can help raise the blood glucose and stabilize it over a longer period. This is a suitable option for treating mild hypoglycemia.
C. Graham crackers: While graham crackers contain carbohydrates, they are not the most immediate or efficient choice in this case. They are slower to digest and may not raise the blood glucose level as quickly as the combination of sugar and protein found in milk.
D. 1 tsp sugar: This is not the best option. While sugar can raise blood glucose, it is a fast-acting form of carbohydrate that may not sustain the client's blood glucose for a longer period. A more balanced option, such as milk, would provide both rapid and sustained glucose elevation.
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