The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems?
(Put a comma and a space between each answer choice [A, B, C, D].)
a. The patient is in a side-lying position with the head of the bed flat.
b. The patient is coughing blood-tinged secretions from the tracheostomy.
c. The nasogastric (NG) tube is disconnected from suction and clamped off.
d. The wound drain in the neck incision contains 200 mL of bloody drainage.
ANS:
A, B, D, C
The patient should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the wound drain should be drained because the 200 mL of drainage will decrease the amount of suction in the wound drain and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting.
You might also like to view...
A patient has an upper motor neuron lesion. The nurse would be correct in assessing for which of the following during assessment of the patient's lower extremities?
A) Muscle spasticity B) Hyporeflexia C) Decreased muscle tone D) Muscle atrophy
Which physical finding should the nurse expect to assess in a patient with alcoholic liver disease?
A) Dyslipidemia B) Insulin resistance C) Palmar erythema D) Hyperglycemia
Which statement accurately describes therapeutic communication?
A. Offering advice and your opinion B. Not verbalizing your feelings C. Avoiding advice, judgment, false reassurance, and approval D. Telling the client how to cope
A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures are completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom." What is the main rationale for communicating these planned nursing interventions?
A. To attempt to establish a trusting relationship B. To provide a structured environment for the client C. To instill hope in the client D. To provide time for completing nursing responsibilities