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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Painful and red-tinged urine may indicate the presence of kidney stones or other urinary issues, but it is not necessarily related to the IV pyelogram or an immediate concern.
B. An allergy to shellfish is critical to report because the contrast dye used in an intravenous pyelogram may contain iodine, which can cause a reaction in individuals with shellfish allergies.
C. The recent end of the client's period is not relevant to the intravenous pyelogram procedure.
D. Drinking 2 quarts of fluid daily is generally adequate and does not require reporting in relation to the procedure.
Correct Answer is D
Explanation
A. Eyelets not being visible may be a normal finding, as they can be covered by the dressing. This is not necessarily indicative of a problem with the chest tube.
B. Crepitus, or subcutaneous emphysema, is concerning and should be monitored but is not immediately life-threatening compared to other signs of complications.
C. Bubbling in the water seal chamber with exhalation is expected and indicates that the chest tube is functioning correctly. Continuous bubbling, however, may suggest an air leak.
D. Movement of the trachea toward the unaffected side is indicative of a mediastinal shift, which can occur due to tension pneumothorax or other significant complications. This is an urgent condition that requires immediate provider notification and intervention.
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