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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The aseptic technique is important to prevent infection when changing the dressing of a central venous access device.
Choice B is not correct because povidone-iodine is not always the recommended cleansing agent for central venous access devices.
Choice C is not correct because a 10-mL syringe may generate too much pressure and damage the catheter.
Choice D is not correct because the dressing does not always need to be changed every 24 hours; the frequency of dressing changes depends on the type of dressing and the condition of the site.

A. Initiate cardiac monitoring for the client. B. Apply a blood pressure cuff. C. Palpate for the client's carotid pulse. D. Establish an IV access.

Correct Answer is C

Explanation

The first step when finding an unresponsive person is to check their breathing by tilting their head back and looking and feeling for breaths.
When a person is unresponsive, their muscles relax and their tongue can block their airway so they can no longer breathe.
Tilting their head back opens the airway by pulling the tongue forward.
Palpating for the client’s carotid pulse is a way to check if the client has a pulse and is still breathing.
Choice A: Initiating cardiac monitoring for the client is not an answer because it is not mentioned as the first action to take in my sources.
Choice B: Apply a blood pressure cuff is not an answer because it is not mentioned as the first action to take in my sources.
Choice D: Establishing an IV access is not an answer because it is not mentioned as the first action to take in my sources.

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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?

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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?