Question

The client has just retumed from the postanesthesia care unit after undergoing a laryngectomy. Which intervention should initially be included in the plan of care?

Answer 1

Correct Answers:

Maintain the head of the bed at 30 to 40 degrees

Rationale :

🌬️Maintaining the head of the bed at 30–40 degrees helps promote airway clearance by reducing edema and aspiration risk.

🛌This position enhances ventilation and lung expansion, which is critical after a laryngectomy.

💉Elevation of the head also supports secretion drainage, which prevents respiratory complications.

⚠️This intervention provides immediate airway protection, which is the first priority in postoperative care.

📌Core Message

After a laryngectomy, keeping the head of the bed elevated supports airway patency, lung expansion, and secretion clearance.

Answer 2

Correct Answers:

Administer 100% oxygen before suctioning

Rationale :

💨Suctioning removes both oxygen and secretions, creating a risk of hypoxemia.

🫁Providing 100% oxygen before suctioning (pre-oxygenation) increases the client’s oxygen reserve.

⚕️This ensures adequate oxygen saturation is maintained during the procedure.

⏱️This intervention prevents desaturation episodes and maintains patient safety.

📌Core Message

Preventing hypoxemia during suctioning is best achieved by pre-oxygenating with 100% oxygen.

Answer 3

Correct Answers:

Unstageable pressure injury

Rationale :

🩹When necrotic eschar covers the wound base, the depth cannot be assessed.

🔬Accurate staging requires visualization of the tissue layers.

🚫The wound is classified as unstageable until debridement exposes the base.

⚠️Correct staging after debridement guides appropriate wound management.

📌Core Message

A wound with eschar covering the base is unstageable because its true depth cannot be determined.

Answer 4

Correct Answers:

One week after menses

Rationale :

🩺During menses, hormonal changes cause breast swelling and tenderness.

📆Performing the exam one week after menses ensures breast tissue is at its baseline state.

👩‍⚕️This timing increases accuracy in detecting lumps or abnormal changes.

⚖️It reduces the chance of false findings caused by normal cyclic changes.

📌Core Message

The most reliable time for a breast self-exam is one week after menses, when the breasts are least affected by hormones.

Answer 5

Correct Answers:

Encourage the client to ambulate.

Rationale :

🚶Ambulation stimulates peristalsis and promotes gas expulsion.

⚕️This helps relieve abdominal discomfort after surgery.

💊Opioids slow GI motility and would worsen gas retention.

🥤Ambulation is the most effective way to restore bowel function naturally.

📌Core Message

Ambulation relieves postoperative gas pain by stimulating peristalsis and gas passage.

Answer 6

Correct Answers:

Beneficence

Rationale :

💙Beneficence means taking action to do what is best for the client and to promote their well-being.

👐By staying and providing emotional support, the nurse ensures the client does not feel abandoned during the dying process.

💊Administering prescribed pain medication demonstrates the nurse’s commitment to relieving suffering and promoting comfort.

🌷This principle reflects compassionate, holistic care that prioritizes comfort, dignity, and quality of life.

📌Core Message

The nurse demonstrates beneficence by ensuring the client receives both comfort and pain relief, highlighting the duty to promote well-being.

Answer 7

Correct Answers:

Communicating orally and in writing

Rationale :

🧠Expressive aphasia occurs due to damage in Broca’s area of the brain, which controls speech production.

🗣️Clients with this condition can usually comprehend spoken language but have difficulty expressing thoughts verbally.

✍️The impairment also affects the ability to communicate through writing, making both spoken and written expression challenging.

⚠️This is distinct from receptive aphasia, where the problem lies in understanding speech, not producing it.

📌Core Message

Expressive aphasia impairs the ability to speak and write, while comprehension of language remains intact.

Answer 8

Correct Answers:

"Syphilis is only a concern if I have pain or discharge."

Rationale :

⚠️Incorrect beliefs about symptoms can delay treatment and increase the risk of transmission.

🦠Primary syphilis begins with a painless chancre, which is highly infectious even without pain or discharge.

💉If left untreated, syphilis progresses to later stages, causing serious systemic complications.

👩‍⚕️Client education is critical to emphasize that contagion and disease progression occur even in the absence of pain.

📌Core Message

Syphilis is contagious even without pain or discharge, and assuming otherwise shows a need for further education.

Answer 9

Correct Answers:

Cool, pale extremities with weak pulses

Rationale :

❄️Arterial insufficiency reduces oxygenated blood flow, resulting in cool and pale extremities.

🫀Weak or absent peripheral pulses are a classic finding due to impaired circulation.

⚠️This is different from venous insufficiency, which is typically associated with swelling, discoloration, and varicosities.

🚶Clients with arterial disease are also at risk for ischemic pain, ulcers, and poor wound healing.

📌Core Message

Arterial insufficiency is characterized by cool, pale extremities and weak pulses because of reduced blood flow.

Answer 10

Correct Answers:

Ask the client to rate their pain on a scale of 0 to 10

Rationale :

🩺Pain is subjective, and the client’s self-report is the most accurate indicator.

🔢Using a 0–10 numerical rating scale allows standardized assessment and tracking of changes.

⚖️Objective signs such as vital signs or facial expressions may support assessment but cannot replace the client’s own description.

👩‍⚕️This ensures effective pain management based on the patient’s reported experience.

📌Core Message

The most reliable way to assess pain is through the client’s self-report using a 0–10 scale.

1 :
The client has just retumed from the postanesthesia care unit after undergoing a laryngectomy. Which intervention should initially be included in the plan of care?

2 :
The nurse is performing tracheostomy care on a client with excessive secretions. Which action will prevent hypoxemia during suctioning?

3 :
The client is admitted with an open pressure injury with necrotic eschar tissue covering the base. How should the nurse stage this client's pressure injury?

4 :
The nurse is educating a client about performing a breast self-examination. The client correctly identifies which of the following as the best time to perform this exam?

5 :
The nurse is caring for a client who is postoperative after abdominal surgery and reporting "gas pains." What action by the nurse can assist the client with alleviating the discomfort associated with gas?

7 :
A client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with which action?

8 :
The nurse is caring for a client with a painless ulcer on their penis who has tested positive for syphilis. Which comment from the client requires additional education?

9 :
The client presents with a diagnosis of arterial insufficiency. When examining the lower extremities, the nurse expects to observe which clinical manifestation?

10 :
The nurse is assessing a client recently returned from surgery. Which is the most appropriate action for the nurse to assess the client's pain?

1 : The client has just retumed from the postanesthesia care unit after undergoing a laryngectomy. Which intervention should initially be included in the plan of care?

2 : The nurse is performing tracheostomy care on a client with excessive secretions. Which action will prevent hypoxemia during suctioning?

3 : The client is admitted with an open pressure injury with necrotic eschar tissue covering the base. How should the nurse stage this client's pressure injury?

4 : The nurse is educating a client about performing a breast self-examination. The client correctly identifies which of the following as the best time to perform this exam?

5 : The nurse is caring for a client who is postoperative after abdominal surgery and reporting "gas pains." What action by the nurse can assist the client with alleviating the discomfort associated with gas?

7 : A client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with which action?

8 : The nurse is caring for a client with a painless ulcer on their penis who has tested positive for syphilis. Which comment from the client requires additional education?

9 : The client presents with a diagnosis of arterial insufficiency. When examining the lower extremities, the nurse expects to observe which clinical manifestation?

10 : The nurse is assessing a client recently returned from surgery. Which is the most appropriate action for the nurse to assess the client's pain?

1 :
The client has just retumed from the postanesthesia care unit after undergoing a laryngectomy. Which intervention should initially be included in the plan of care?

2 :
The nurse is performing tracheostomy care on a client with excessive secretions. Which action will prevent hypoxemia during suctioning?

3 :
The client is admitted with an open pressure injury with necrotic eschar tissue covering the base. How should the nurse stage this client's pressure injury?

4 :
The nurse is educating a client about performing a breast self-examination. The client correctly identifies which of the following as the best time to perform this exam?

5 :
The nurse is caring for a client who is postoperative after abdominal surgery and reporting "gas pains." What action by the nurse can assist the client with alleviating the discomfort associated with gas?

7 :
A client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with which action?

8 :
The nurse is caring for a client with a painless ulcer on their penis who has tested positive for syphilis. Which comment from the client requires additional education?

9 :
The client presents with a diagnosis of arterial insufficiency. When examining the lower extremities, the nurse expects to observe which clinical manifestation?

10 :
The nurse is assessing a client recently returned from surgery. Which is the most appropriate action for the nurse to assess the client's pain?