A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make?

"Tuck your chin when you swallow so you won't choke."

"You should have no trouble swallowing fluids."

"I will add a thickener to your liquids to prevent aspiration."

"It is no longer possible for you to choke on or aspirate food."

Answer and Explanation

The Correct Answer is C

A. Tucking the chin when swallowing can help reduce the risk of aspiration in clients with certain conditions, but after a total laryngectomy, clients are at increased risk for aspiration due to altered anatomy and should have thickened liquids to minimize this risk.

B. Clients who have undergone a total laryngectomy may have difficulties with swallowing and are at risk of aspiration. It is not accurate to say they will have no trouble swallowing fluids without proper assessment and adaptation.

C. Adding a thickener to liquids is a recommended intervention to reduce the risk of aspiration in clients who have had a laryngectomy, as thickened fluids are less likely to be aspirated into the lungs compared to thin liquids.

D. Clients who have had a total laryngectomy are still at risk for choking or aspiration due to changes in their swallowing mechanics and altered anatomy. It is important to take preventive measures, such as thickening liquids.

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Correct Answer is D

Explanation

A. 4 mm erythema is generally considered negative or not indicative of TB exposure.
B. 10 mm wheal is an inadequate measurement; a wheal indicates a local reaction but not the size of induration.
C. 5 mm induration may be considered positive in high-risk individuals but is generally not sufficient for standard TB testing.
D. 15 mm induration is indicative of a positive TB test, suggesting significant exposure and possible infection. This measurement is used for clients at average risk.

A. Apply wrist and leg restraints to the client. B. Call the family and ask them to stay with the client. C. Administer medication to sedate the client. D. Move the client to a room closer to the nurses' station.

Correct Answer is D

Explanation

A. Applying restraints should be a last resort and only if less restrictive measures have failed. It is also essential to follow legal and ethical guidelines regarding the use of restraints.

B. Calling the family to stay with the client may provide temporary comfort but does not directly address safety concerns or the underlying cause of restlessness and confusion.

C. Sedating the client might not be appropriate without first assessing the cause of the restlessness and confusion. Medications should be used cautiously and based on a thorough evaluation.

D. Moving the client closer to the nurses' station allows for more frequent monitoring and quick intervention if needed, addressing the immediate safety concern of restlessness and confusion. This measure helps ensure the client’s safety while further assessment and intervention are being planned.

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A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make?

Nursing Test Bank

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