A nurse is caring for a client who has just undergone a total laryngectomy.
Which of the following findings is the nurse's priority for immediate intervention?
Fever.
Blood-tinged secretions.
Tachypnea.
IV infiltration.
The Correct Answer is C
The nurse’s priority for immediate intervention is tachypnea, which is rapid breathing.
Tachypnea can be a sign of respiratory distress and requires immediate intervention.
Choice A is wrong because while a fever may indicate an infection, it is not the priority for immediate intervention.
Choice B is wrong because while blood-tinged secretions may indicate bleeding, it is not the priority for immediate intervention.
Choice D is wrong because while IV infiltration may cause discomfort and require attention, it is not the priority for immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A 10-mL syringe is the minimum size that should be used to flush a PICC line to prevent damage to the catheter.
Choice A, Clean the insertion site using 20 mL of hydrogen peroxide, is not the correct answer because hydrogen peroxide should not be used to clean the insertion site of a PICC line.
Choice B, Changing the catheter dressing daily, is not the correct answer because the catheter dressing should be changed every 3 to 7 days or as directed by a healthcare provider.
Choice D, Do not elevate the arm above the level of the heart, is not the correct answer because there is no restriction on elevating the arm above the level of the heart with a PICC line.
Correct Answer is C
Explanation
“You should expect a warm sensation after the injection of the contrast dye during the procedure.” During cardiac catheterization, a contrast dye is injected into the body to highlight blood flow through the arteries and show blockages in the blood vessels that lead to the heart.
This can cause a warm sensation.
Choice A is incorrect because usually, patients are awake during cardiac catheterization but are given medications to help them relax.
Choice B is incorrect because recovery time for a cardiac catheterization is quick.
Choice D is incorrect because there is no information found to support this statement.
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