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 C

Explanation

A. Hepatitis B is a viral infection and is not typically a concern for asthma patients in terms of environmental triggers.
B. Radon is a radioactive gas that can cause lung cancer with long-term exposure, but it is not a common asthma trigger.
C. Mold is a common environmental allergen and asthma trigger. It can exacerbate asthma symptoms and lead to allergic reactions, so it is important for clients with asthma to avoid mold exposure.
D. Cockroaches are another common asthma trigger, and clients with asthma should avoid exposure to cockroach allergens.

A. Stop the infusion. B. Elevate the head of the bed. C. Auscultate the client's breath sounds. D. Call the client's provider.

Correct Answer is A

Explanation

A. The client is likely experiencing an allergic reaction to penicillin, such as anaphylaxis, which can cause symptoms like itching, dizziness, and difficulty breathing. The first step is to stop the infusion immediately to prevent further exposure to the allergen.
B. Elevating the head of the bed might be helpful if the client is experiencing respiratory distress, but stopping the infusion is the priority action.
C. Auscultating the client's breath sounds may be useful later to assess the severity of respiratory distress, but it is not the first action in an acute allergic reaction.
D. Calling the provider is important, but the immediate priority is stopping the infusion to prevent further harm from the allergic reaction.

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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

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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