Which action would the nurse take first for a patient with a tracheostomy who appears anxious and is having difficulty in coughing up thick respiratory secretion?

Encourage the patient to increase oral fluid intake.

Apply humidification to the patient's oxygen.

Suction the tracheostomy.

Offer reassurance.

Answer and Explanation

The Correct Answer is C

A. Encouraging the patient to increase oral fluid intake may help with secretion thinning over time, but in the immediate situation of thick respiratory secretions, it will not provide immediate relief.
B. Applying humidification to the oxygen would be helpful over time to thin secretions, but it is not the immediate action needed to address the difficulty in clearing thick secretions.
C. Suctioning the tracheostomy is the priority action in this situation. When a patient with a tracheostomy has difficulty clearing thick secretions, suctioning is the most effective way to relieve the obstruction and improve airflow, thereby addressing the immediate respiratory distress.
D. Offering reassurance is important, but it does not address the patient’s immediate need to clear the airway. Managing the respiratory distress should take priority.

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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.

A. "Because of your surgery, you have an altered ability to smell and taste." B. "I would be happy to get you food that you prefer to eat." C. "Clients frequently complain about the taste of hospital food." D. "You should ask your family to bring you some food from home."

Correct Answer is A

Explanation

A. A total laryngectomy involves the removal of the larynx, which can impact both the ability to smell and taste. This is due to the altered airflow and the loss of normal sensory processes. Explaining this to the patient is an appropriate response.
B. While offering to provide preferred foods may seem empathetic, it does not address the underlying issue, which is the loss of taste and smell due to the surgery.
C. Telling the client that hospital food is often tasteless does not address the patient's specific condition and may seem dismissive of their concerns.
D. While it might be helpful for the family to bring food, the nurse should first address the reason for the altered taste perception and educate the patient accordingly.

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Which action would the nurse take first for a patient with a tracheostomy who appears anxious and is having difficulty in coughing up thick respiratory secretion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

A nurse is caring for a client who is 1-day postoperative following a total laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse that the hospital food has no taste. Which of the following responses is appropriate for the nurse to make?

Correct Answer is A

Explanation

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