After observing blood-tinged mucous when suctioning a patient who has just arrived on the medical-surgical unit after a laryngectomy, which action by the nurse is best?
Place the patient in a lateral recovery position for better drainage of the secretions.
Activate the rapid-response team.
Keep monitoring the oxygen saturation and respiratory rate.
Increase the humidification of the patient's oxygen.
The Correct Answer is A
A. Placing the patient in a lateral recovery position is the best immediate action. This position helps facilitate drainage of secretions, especially after a laryngectomy, which can reduce the risk of aspiration and airway obstruction. The blood-tinged mucus may be due to recent surgery and should be monitored for changes.
B. The activation of the rapid-response team may be necessary if the patient’s condition worsens or becomes critical, but there is no indication of an acute life-threatening event based on the blood-tinged mucus alone.
C. Monitoring the oxygen saturation and respiratory rate is important, but it is a secondary concern compared to providing a position that promotes drainage and prevents aspiration.
D. Increasing humidification of the oxygen may help keep the airway moist, but the immediate priority should be ensuring proper positioning to allow secretion drainage and prevent aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hirsutism, or excessive hair growth, is more commonly associated with conditions such as polycystic ovary syndrome (PCOS) or Cushing’s syndrome, rather than Addison’s disease.
B. Hyperpigmentation is a characteristic sign of Addison’s disease. Due to insufficient cortisol production in the adrenal glands, there is an increase in melanocyte-stimulating hormone (MSH), which leads to darkening of the skin, particularly in areas exposed to friction like elbows, knees, and the face.
C. Purple striations are a common finding in Cushing’s syndrome, which results from excessive cortisol production. They are not typically seen in Addison's disease.
D. Intention tremors are more commonly associated with neurological conditions, such as Parkinson’s disease, rather than Addison’s disease, which primarily affects the adrenal glands.
Correct Answer is A
Explanation
A. After administering a carbohydrate source (e.g., 6 oz of orange juice), the nurse should reassess the patient's blood glucose level. If the glucose is still below the target range (typically above 70 mg/dL), the next step is to give an additional 15 grams of carbohydrate to raise the blood sugar. This is a standard approach for mild to moderate hypoglycemia.
B. Giving 25 to 50 ml of 50% glucose IV is typically reserved for patients who are severely hypoglycemic and unable to swallow or are unresponsive. This method is appropriate when the patient cannot take oral glucose, but the client in this scenario is still conscious.
C. Administering 1 mg IM glucagon is used when a patient is unable to ingest glucose orally and is unresponsive or vomiting. It stimulates the liver to release stored glucose, but this is not necessary in a conscious patient who can swallow.
D. Administering a 5% to 10% dextrose infusion is typically used in more severe cases of hypoglycemia, especially when IV access is established, and the patient is unable to take oral glucose. This would not be necessary for a patient who can safely swallow.
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