a nurse is caring for a client following a total laryngectomy which of the following is the priority observation in the clients care
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Nursing Elites

ATI RN

ATI Detailed Answer Key Medical Surgical

1. A client underwent a total laryngectomy. Which of the following is the priority observation in the client's care?

Correct answer: D

Rationale: Following a total laryngectomy, maintaining a clear airway is crucial to prevent complications such as airway obstruction due to secretions or blood clots. Monitoring the need for suctioning takes precedence to ensure the client's airway remains patent. While monitoring pain levels, IV line patency, and dressing integrity are important aspects of care, ensuring adequate airway clearance through suctioning is the priority in this scenario.

2. While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?

Correct answer: B

Rationale: When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.

3. A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?

Correct answer: D

Rationale: After a total hip replacement, clients should avoid bending at the waist past 90 degrees for at least 6 weeks to prevent dislocation of the hip prosthesis. Bending down to tie shoes involves significant hip flexion and should be avoided during the initial postoperative period to ensure proper healing and reduce the risk of complications.

4. How does the pain of a myocardial infarction (MI) differ from stable angina?

Correct answer: A

Rationale: The pain of an MI is often accompanied by shortness of breath and feelings of fear or anxiety. It typically lasts longer than 15 minutes and is not relieved by nitroglycerin. Unlike stable angina, the pain of an MI occurs without a known cause such as exertion.

5. A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond?

Correct answer: C

Rationale: Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client & partner to be tested for the abnormal gene. The other statements are not true.

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