A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

Explain the techniques of esophageal speech.

Schedule a support session for the client.

Determine the client's reading ability.

Review the use of an artificial larynx with the client.

None

Answer and Explanation

The Correct Answer is C

A. Explain the techniques of esophageal speech. Esophageal speech is one method of communication but is learned later through speech therapy. Not the immediate priority.

B. Schedule a support session for the client. While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.

C. Determine the client's reading ability. After surgery, the client will not be able to speak initially. Knowing if the client can read and write allows the nurse to provide a communication method (such as writing or using a communication board) to meet immediate needs, especially related to airway, pain, and care.

D. Review the use of an artificial larynx with the client. An electrolarynx is an option but is introduced later in recovery. It is not the immediate concern before surgery.

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Correct Answer is A

Explanation

The correct answer is that the nurse should dangle the client's arm over the edge of the bed to help dilate the vein. This technique uses gravity to increase blood ﬂow to the arm and dilate the veins, making it easier to insert a peripheral IV catheter.

Options b, c and d are not eﬀective techniques for dilating a vein for IV insertion. Stroking the skin near the vein in an upward direction, instructing the client to ﬂex their arm with the hand open and applying a cool compress to the vein for 10 min are not eﬀective methods for dilating a vein.

A. The client's room number B. The client's admitting diagnosis C. The name of the client's next of kin D. The client's telephone number

Correct Answer is D

Explanation

The nurse should plan to use the client's telephone number to confirm their identity. This is because the telephone number is a unique identifier that is directly associated with the client and can be easily verified. By comparing the client's telephone number with the information on the medication administration record or electronic health record, the nurse can ensure that the right medication is given to the right patient.
Explanation:
a) The client's room number is not a reliable method to confirm the client's identity because multiple clients may be assigned to the same room, and there is a possibility of room changes or transfers.
b) The client's admitting diagnosis is not a suitable method to confirm identity as it does not provide specific information about the individual patient.
c) The name of the client's next of kin is not a reliable method to confirm the client's identity as it refers to a family member or emergency contact, not the client themselves. Additionally, next of kin information may not always be up to date or readily available.

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A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert a peripheral IV catheter into a client's arm. Which of the following actions should the nurse take to help dilate the vein?

Correct Answer is A

Explanation

A nurse is preparing to administer several medications to a client. Which of the following data should the nurse plan to use to confirm the client's identity?

Correct Answer is D

Explanation

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