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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.
Correct Answer is D
Explanation
A. A BMI of 28 kg/m² is considered overweight, but it does not meet the threshold for bariatric surgery, which typically requires a BMI of 40 or more.
B. While a BMI of 32 kg/m² may be relevant when combined with significant co-morbidities (like type 2 diabetes or hypertension), the standard guideline for bariatric surgery generally requires a BMI of 40 or higher, or 35 with comorbid conditions.
C. A BMI of 30 kg/m² is classified as obese, but bariatric surgery is generally considered for those with a BMI of 40 or higher, or 35 with severe comorbidities.
D. A BMI of 40 kg/m² or more is the standard criteria for bariatric surgery, particularly when other treatments (such as diet, exercise, and medication) have failed, or when obesity-related health issues are present.
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