Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

Clubbing of the fingernails

Tracheal deviation

Contraction of the diaphragm

Auscultation of rhonchi throughout the lungs

Answer and Explanation

The Correct Answer is B

A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.

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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.

A. Tissue integrity B. Airway patency C. Pain severity D. Wound drainage

Correct Answer is B

Explanation

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.

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Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

Correct Answer is B

Explanation

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