A nurse is caring for a client following a total laryngectomy.
Which of the following is the priority observation in the client's care?
The client's airway.
Level of pain.
Patency of the intravenous line.
Integrity of the dressing.
The Correct Answer is A
Choice A rationale
Following this major surgical procedure, the most critical nursing priority is ensuring that the client has a patent path for gas exchange. The removal of the larynx necessitates a permanent stoma, and any obstruction from secretions, blood, or edema can lead to rapid respiratory arrest. Constant monitoring of respiratory rate, effort, and oxygen saturation is vital. Airway management always takes precedence over other assessments in the immediate postoperative period to prevent life-threatening hypoxia or asphyxia.
Choice B rationale
While managing discomfort is a significant part of postoperative care and promotes recovery, it does not pose an immediate threat to life. Pain can increase heart rate and blood pressure, making the client restless, but it is considered secondary to the physiological need for oxygenation. The nurse should address pain through pharmacological and non-pharmacological means only after confirming that the respiratory status is stable. Pain assessment is important for holistic care but remains a lower priority.
Choice C rationale
Maintaining access for fluids and medications is necessary for hydration and the administration of antibiotics or analgesics. However, a displaced or occluded intravenous line is a circulatory issue that can be addressed after the airway is secured. While critical for long-term recovery and stability, it does not require the same level of emergent vigilance as the respiratory system. The nurse must ensure the line is patent but only after performing a thorough respiratory assessment.
Choice D rationale
Monitoring the surgical site for bleeding, hematoma formation, or signs of infection is a standard postoperative task. A tight or soiled dressing can indicate complications, but it is not as immediately life-threatening as a blocked airway. Integrity of the site is important for wound healing and preventing sepsis, but it falls under the category of "circulation" or "skin integrity" in the priority hierarchy. Airway patency must always be the first concern for a post-laryngectomy client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
These low-pitched, continuous sounds are typically caused by secretions or obstructions in the larger airways, such as the bronchi. They often sound like snoring and may clear with coughing. Pleurisy involves the inflammation of the pleural membranes rather than the accumulation of mucus in the bronchial tree. Therefore, hearing these sounds would suggest a different underlying condition, such as bronchitis or chronic obstructive pulmonary disease, rather than the sharp inflammation associated with pleural friction.
Choice B rationale
This specific sound occurs when the inflamed visceral and parietal pleurae grate against each other during inspiration and expiration. It is described as a localized, dry, creaking, or grating sound that resembles the noise made by rubbing two pieces of leather together. This is a hallmark finding in pleurisy because the normally smooth, lubricated surfaces of the lungs and chest wall become roughened and painful. It is usually heard best over the area of maximum pain.
Choice C rationale
These high-pitched, musical whistling sounds are caused by air moving through narrowed or constricted small airways. This narrowing is common in conditions like asthma or anaphylaxis where bronchospasm occurs. While pleurisy causes pain that may lead to shallow breathing, it does not typically cause the systemic airway narrowing that results in wheezing. The pathology of pleurisy is external to the bronchi, focusing on the lining of the thoracic cavity and the outer surface of the lungs.
Choice D rationale
These discontinuous, popping sounds are usually produced by the sudden opening of small airways or alveoli that contain fluid or are collapsed. They are frequently associated with conditions like heart failure, pulmonary edema, or pneumonia. While a client with pleurisy might develop a secondary infection, the primary inflammation of the pleural layers itself does not produce crackles. Crackles indicate fluid in the alveolar spaces, whereas pleurisy involves friction between the two pleural membranes during the respiratory cycle.
Correct Answer is ["415"]
Explanation
Step 1 is (30 mL × 2) = 60 mL.
Step 2 is 475 mL - 60 mL = 415 mL.
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.