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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. A peak flow of more than 40% would indicate that the patient's asthma is not in an acute exacerbation. This patient's symptoms, such as confusion and inability to speak, suggest a severe asthma attack, and the peak flow would likely be much lower.
B. Bradycardia is not typically associated with severe asthma exacerbations. Tachycardia is more commonly observed as the body attempts to compensate for hypoxia.
C. Loud and prominent wheezing is usually seen in less severe cases of asthma. In this case, the inability to speak and confusion suggest severe respiratory distress, where wheezing might be diminished or absent due to poor air movement.
D. Deteriorating arterial blood gas (ABG) results, with low oxygen levels (hypoxemia) and elevated carbon dioxide levels (hypercapnia), would be expected in a patient with severe asthma exacerbation. These signs indicate respiratory failure and the need for urgent intervention.

A. "It is caused by the lack of production of insulin by the pancreas." B. "It is caused by the overproduction of parathormone by the parathyroid gland." C. "It is caused by the lack of production of aldosterone by the adrenal gland." D. "It is caused by the overproduction of growth hormone by the pituitary gland."

Correct Answer is C

Explanation

A. "It is caused by the lack of production of insulin by the pancreas.": This is incorrect. The lack of insulin production causes diabetes mellitus, not Addison’s disease. Addison’s disease results from insufficient production of adrenal hormones, particularly aldosterone and cortisol.
B. "It is caused by the overproduction of parathormone by the parathyroid gland.": This is incorrect. Parathormone is produced by the parathyroid glands and regulates calcium balance, but overproduction of parathormone leads to conditions such as hyperparathyroidism, not Addison’s disease.
C. "It is caused by the lack of production of aldosterone by the adrenal gland.": This is correct. Addison’s disease, also known as primary adrenal insufficiency, is caused by the inability of the adrenal glands to produce sufficient aldosterone and cortisol, two critical hormones. Aldosterone helps regulate sodium and potassium balance, and cortisol helps the body respond to stress.
D. "It is caused by the overproduction of growth hormone by the pituitary gland.": This is incorrect. Overproduction of growth hormone causes acromegaly or gigantism, not Addison’s disease. Addison’s disease results from adrenal insufficiency, not pituitary gland dysfunction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with asthma is admitted with severe dyspnea and is unable to speak. The nurse finds that the patient looks drowsy and confused. Which other finding would the nurse expect?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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