A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client's care?
Patency of the intravenous line.
Need for suctioning.
Integrity of the dressing.
Level of pain.
The Correct Answer is B
Suctioning is the priority observation in the client's care, as it prevents airway obstruction and respiratory distress caused by blood, mucus, or secretions. The client has a permanent tracheostomy and cannot cough or clear the airway effectively. The nurse should assess the need for suctioning frequently and perform it as needed, using sterile technique and maintaining oxygenation.
a) Patency of the intravenous line is important, but not the priority observation in the client's care. The intravenous line provides fluids, electrolytes, and medications to the client, but it does not affect the airway patency or oxygenation.
c) Integrity of the dressing is important, but not the priority observation in the client's care. The dressing protects the surgical site from infection and bleeding, but it does not affect the airway patency or oxygenation.
d) Level of pain is important, but not the priority observation in the client's care. The pain can be managed with analgesics and nonpharmacological measures, but it does not affect the airway patency or oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer: B
Rationale:
A) "Expect your sputum cultures to be negative after 6 months of therapy":
While sputum cultures may become negative after a period of effective therapy, it is not always guaranteed to happen within exactly 6 months. Tuberculosis (TB) treatment usually involves several months of medication, and sputum cultures are monitored periodically to assess treatment efficacy, not solely at the 6-month mark.
B) "Drink at least 8 ounces of water when you take the pyrazinamide tablet":
Drinking plenty of water with pyrazinamide is important to prevent dehydration and to help minimize potential side effects, such as hyperuricemia or gout. Adequate hydration can also aid in the effective elimination of the medication from the body, thus reducing the risk of adverse effects.
C) "Provide a sputum specimen every 2 weeks to the clinic for testing":
Sputum specimens are typically provided less frequently than every 2 weeks, usually monthly, to monitor the progress of TB treatment. Testing frequency may vary depending on the client's condition and the healthcare provider's recommendations.
D) "Take isoniazid with an antacid":
Isoniazid should not be taken with antacids, as antacids can interfere with the absorption of isoniazid. It is usually advised to take isoniazid on an empty stomach, and clients should be instructed to wait at least 1 hour after taking isoniazid before consuming antacids.
Correct Answer is D
Explanation
Smoking cessation is the most effective way to prevent chronic bronchitis, which is a type of chronic obstructive pulmonary disease (COPD) characterized by inflammation and excess mucus production in the
bronchi. Smoking is the main cause of chronic bronchitis, as it damages the cilia and mucous membranes of the airways, leading to chronic cough, sputum, and infection. Quitting smoking can reduce the risk of developing or worsening chronic bronchitis and improve lung function and quality of life.
a) Regular moderate exercise is beneficial for preventing chronic bronchitis, but not as effective as smoking cessation. Exercise can improve cardiovascular and respiratory health, increase oxygen delivery to the tissues, and enhance immune function. However, exercise alone cannot reverse the damage caused by smoking or prevent further deterioration of the airways.
b) Maintenance of ideal weight is beneficial for preventing chronic bronchitis, but not as effective as smoking cessation. Maintaining a healthy weight can reduce the workload on the heart and lungs, prevent obesity-related complications, and improve self-esteem and well-being. However, weight management alone cannot restore the normal structure and function of the airways or prevent chronic inflammation and mucus production.
c) Annual influenza immunization is beneficial for preventing chronic bronchitis, but not as effective as smoking cessation. Influenza immunization can protect against viral infections that can trigger or exacerbate chronic bronchitis symptoms, such as fever, cough, wheezes, and dyspnea. However, influenza immunization cannot prevent other causes of chronic bronchitis, such as bacterial infections, environmental pollutants, or genetic factors.
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