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

Correct answer: Need for suctioning

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. A client with asthma has developed viral pharyngitis. Which of the following findings should the nurse expect?

Correct answer: Negative throat culture

Rationale: Viral pharyngitis is typically caused by a virus, not bacteria, so a negative throat culture is an expected finding. The presence of petechiae on the chest and abdomen (Choice A) is not a common manifestation of viral pharyngitis. Elevated WBC count (Choice B) is more indicative of a bacterial infection rather than a viral one. Severe hyperemia of the pharyngeal mucosa (Choice D) is a possible finding in pharyngitis but is not specific to viral pharyngitis.

3. A nurse is providing discharge teaching to a client with a prescription for home oxygen therapy. What information should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Avoid open flames or smoking near oxygen.' This information is crucial to prevent fire hazards as oxygen supports combustion. Choices A, B, and D are incorrect. Increasing the oxygen flow rate without healthcare provider's instructions can be dangerous. Oxygen should not be turned off when not in use as prescribed by the healthcare provider, and storing oxygen tubing near heat sources poses a risk of fire.

4. If a pair of monozygotic twins raised in the same environment end up being different from one another (e.g., interests, hobbies, etc.), it is highly likely due to:

Correct answer: B

Rationale: The correct answer is B: Proximodistal pattern. Differences between monozygotic twins raised in the same environment are likely due to non-shared environmental influences, which lead to differences in interests, hobbies, and other individual characteristics. Choices A, C, and D are incorrect. Cephalocaudal pattern refers to the principle of development from head to toe, not relevant in explaining differences between twins. Cephamodistal pattern is not a recognized developmental term. Gene-environment correlation does not directly explain the differences between identical twins raised in the same environment.

5. A nurse is reviewing the medical record of a client who has a history of angina and is scheduled for surgery. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: The correct answer is D. An INR of 2.0 is within the therapeutic range for clients receiving warfarin. It is crucial to report this finding to the provider before surgery to ensure appropriate management and potential adjustments to prevent excessive bleeding risks. Choices A, B, and C are within normal limits and do not directly impact the client's surgery preparation or risk for bleeding, so they do not require immediate reporting.

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