The nurse is preparing the care plan for a patient who is scheduled for a laryngectomy. Which nursing diagnosis should receive the highest priority?
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
C
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An adult patient has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this patient's plan of care?
A) Measure the patient's abdominal girth daily. B) Limit the use of opioid analgesics. C) Monitor the patient for signs of dysphagia. D) Encourage activity as tolerated.
The pediatric clinic nurse is aware that the most common time for the infant to begin to roll over occurs at approximately:
A) One month of age B) Two months of age C) Three months of age D) Four months of age
An example of verbal abuse is
A) making gestures that frighten the patient. B) acting in a way that causes the patient to be afraid of you. C) calling the patient unkind names. D) seductive, sexually demeaning behavior.
A patient using a nasal cannula has gurgling on inspiration. The nurse notes a productive cough but the inability to clear the secretions from the mouth. Which action should the nurse take first to prepare for oropharyngeal suctioning?
a. Apply clean gloves and a mask. b. Insert the suction device to the back of the throat. c. Remove the patient's nasal cannula. d. Connect the tubing to a standard suction catheter.