You are caring for a patient who is scheduled for a laryngectomy. You are preparing the patient's care plan. Which nursing diagnoses should receive the highest priority for this surgery?
A) Anxiety related to diagnosis of cancer
B) Altered nutrition related to swallowing difficulties
C) Ineffective airway clearance related to surgical alterations in the airway
D) Impaired verbal communication related to removal of the larynx
Ans: C
Feedback: Each of the listed diagnoses is valid, but ineffective airway clearance is the priority nursing diagnosis for all conditions. Therefore, options A, B, and D are incorrect.
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The nurse is caring for a geriatric client with thin, chapped, itchy skin. Which nursing intervention should the nurse alter in the plan of care?
A) Use of a gait belt for ambulation B) Maintenance of foam pad on wheelchair C) Daily bathing with warm-hot water D) Applying lanolin ointment
The nurse is caring for an infant with a temporary ileostomy. As part of the plan of care, the nurse monitors for skin breakdown around the stoma
If redness occurs, which of the following would be most appropriate to promote healing and prevent further skin breakdown? A) Clean the area well with a scented diaper wipe. B) Apply a barrier/healing cream or paste on the skin. C) Use a barrier wafer (such as Stomahesive) to attach the appliance. D) Sanitize the area with an alcohol wipe after each diaper change.
Common causes of pressure ulcers include which of the following?
a. Pressure b. Use of pillows for positioning c. A good blood supply d. Burns
The nurse is reviewing a client's laboratory results. Which finding is of most concern?
1. HDL cholesterol 62 mg/dL 2. Triglycerides 349 mg/dL 3. LDL cholesterol 92 mg/dL 4. Total cholesterol 202 mg/dL