A nurse is caring for a patient who has just undergone a laryngectomy. What action should the nurse take in this situation?
Position the head of the patient’s bed flat.
Provide the patient with humidified air.
Clean the patient’s sutures every 8 hours.
Suction the patient’s mouth on the side of the surgery.
The Correct Answer is B
Choice A rationale
Positioning the head of the patient’s bed flat is not typically recommended after a laryngectomy. Instead, the head of the bed is often elevated to help reduce swelling and improve breathing.
Choice B rationale
Providing the patient with humidified air can help keep the airway moist and reduce discomfort, making it a common practice after a laryngectomy.
Choice C rationale
While keeping the surgical site clean is important, cleaning the patient’s sutures every 8 hours is not a standard recommendation and may vary based on the surgeon’s instructions.
Choice D rationale
Suctioning the patient’s mouth on the side of the surgery is not typically recommended as it could potentially disrupt the surgical site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
Choice A rationale: CNS manifestations such as headaches are not a therapeutic effect of nafarelin. These are side effects of the medication. Nafarelin, a gonadotropin-releasing hormone (GnRH) agonist, works by reducing the production of estrogen in the body. This can lead to a variety of side effects, including headaches. While these side effects can be bothersome, they do not indicate that the medication is effectively treating the endometriosis.
Choice B rationale: The reduction in pain level during sexual intercourse, or dyspareunia, is a therapeutic effect of nafarelin. Endometriosis can cause painful sexual intercourse, and one of the goals of treatment with nafarelin is to reduce this pain. The client’s report of decreased dyspareunia suggests that the nafarelin is effectively treating the endometriosis.
Choice C rationale: Changes in the nasal mucosa, such as irritation, are not a therapeutic effect of nafarelin. These are side effects of the medication. Nafarelin is administered intranasally, which can lead to irritation of the nasal mucosa. While this side effect can be bothersome, it does not indicate that the medication is effectively treating the endometriosis.
Choice D rationale: Changes in breast size are not a therapeutic effect of nafarelin. These are side effects of the medication. Nafarelin can cause a variety of side effects, including changes in breast size. While this side effect can be bothersome, it does not indicate that the medication is effectively treating the endometriosis.
Choice E rationale: The absence of menstruation, or amenorrhea, is a therapeutic effect of nafarelin. Nafarelin works by reducing the production of estrogen in the body, which can lead to a temporary halt in menstruation. This is a therapeutic effect as it can help to reduce the pain and other symptoms associated with endometriosis.
Choice F rationale: Dermatological manifestations such as increased acne are not a therapeutic effect of nafarelin. These are side effects of the medication. Nafarelin can cause a variety of side effects, including increased acne. While this side effect can be bothersome, it does not indicate that the medication is effectively treating the endometriosis.
Correct Answer is A
Explanation
Choice A rationale
A negative rubella titer indicates that the patient does not have immunity to the rubella virus. Therefore, the patient would need a rubella vaccination after delivery to prevent future infection.
Choice B rationale
A negative rubella titer does not necessarily mean that the patient is not currently infected with rubella. It simply means that the patient does not have immunity to the virus.
Choice C rationale
A negative rubella titer indicates that the patient is not immune to the rubella virus, not that they are immune.
Choice D rationale
While the patient does need a rubella vaccination, it is not typically given during pregnancy due to the theoretical risk to the fetus. Instead, it is usually given after delivery.
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