Mrs. Newman has been experiencing hoarseness and a change in her voice, but she did not seek medical help until she began to have difficulty swallowing. After being seen by her healthcare provider, she is scheduled for outpatient surgery for a direct laryngoscopy to obtain a culture and take a biopsy.
Mrs. Newman arrives at the outpatient surgical department at 6:30 a.m. and is escorted to her room. The admitting nurse begins her assessment.
1.
Which question is most important for the nurse to ask Mrs. Newman?
A) Have you smoked any cigarettes in the last 24 hours?
INCORRECT
Although smoking cigarettes is a risk factor for laryngeal cancer, this is not the most important question to ask prior to the procedure.
B) When was the last time you drank any alcohol?
INCORRECT
Even though alcohol and tobacco use are directly related to developing laryngeal cancer, this is not the most important question to ask prior to the procedure.
C) Have you had anything to eat or drink since midnight?
CORRECT
Eating and/or drinking places the client at risk for vomiting and aspiration during the procedure. If Mrs. Newman has had anything to eat or drink, the biopsy would be cancelled.
D) Are you taking any medications?
INCORRECT
Although the client's answer may provide pertinent information, this is not the most important question to ask prior to the surgical procedure.
2.
The admission nurse completes the admission assessment and starts an IV of 1000 cc of normal saline prescribed to run over 10 hours. The drop factor on the tubing is 10 drops/minute (gtts/min). How many drops per minute should the nurse set the IV pump to deliver? (Enter the numerical value only. If rounding is required, round to the whole number.)
CORRECT
1000 cc/600 min X 10 gtts = 16.6 rounded to 17 gtts/min
Mrs. Newman is taken to the operating room for the biopsy. After the procedure, Mrs. Newman is admitted into the Post Anesthesia Care Unit (PACU).
3.
Which intervention will the PACU nurse implement first?
A) Obtain Mrs. Newman's vital signs.
CORRECT
Vital signs should be assessed first to establish a baseline for the post-anesthesia period.
B) Assess Mrs. Newman's gag reflex.
INCORRECT
Assessing Mrs. Newman's gag reflex must be done prior to her receiving oral fluids, but it is not the first nursing intervention that should be implemented.
C) Monitor Mrs. Newman's pulse oximeter.
INCORRECT
Considering Mrs. Newman's smoking history, this would be important, but it is not the intervention that should be implemented first.
D) Check the healthcare provider's prescriptions.
INCORRECT
Checking the healthcare provider's prescriptions must be done, but it is not the first intervention the recovery nurse should implement.
Mrs. Newman has no complications from the biopsy procedure. Her healthcare provider informs her that she has stage IV laryngeal cancer and refers her to an oncologist. The oncologist discusses treatment options and recommends a total laryngectomy. The oncologist explains the procedure and tells Mrs. Newman to call the office when she decides which treatment she wants.
Pre-hospital Nursing Interventions
After 2 days, Mrs. Newman calls the oncologist and reluctantly agrees to a total laryngectomy. Mrs. Newman comes to the oncology office to meet with the oncology nurse specialist (ONS) to discuss the preoperative and postoperative care. Mrs. Newman tells the ONS that she is very scared about having this surgery. She says that she has no questions about the medical aspects of the procedure but states she is concerned about how her life will change. She tells the nurse that she realizes she needs to have the surgery but is ambivalent and doesn't know if she will be able to go through with it after all.
4.
Which nursing intervention is most helpful to Mrs. Newman?
A) Ask Mrs. Newman if she would like to talk to someone who has had this surgery.
CORRECT
Mrs. Newman may feel more comfortable asking questions and expressing her fears to someone who has undergone the same procedure. The International Association of Laryngectomees and the American Cancer Society Visitor Program are 2 organizations that provide this service.
B) Refer Mrs. Newman to a psychologist to discuss her fears about having this surgery.
INCORRECT
There is a better intervention to meet the client's needs.
C) Tell Mrs. Newman it is OK to be scared and hold her hand.
INCORRECT
While this acknowledges her fears and offers support, there is a better intervention to meet the client's needs.
D) Give Mrs. Newman literature provided by the American Cancer Society.
INCORRECT
While written information is an important part of teaching, there is a better intervention to meet the client's needs.
Mrs. Newman is concerned about singing in the country and western club and asks the ONS, "How long do you think it will before I can sing with my band again?"
5.
How should the ONS respond?
A) Request that the oncologist visit with Mrs. Newman and explain the procedure to her again.
INCORRECT
Even though Mrs. Newman may not understand the ramifications of the surgery, the nurse can answer this question.
B) Explain that her vocal cords will be removed, and she will not be able to sing.
CORRECT
Mrs. Newman needs the correct information prior to having a total laryngectomy.
C) Ask Mrs. Newman if she understands what a total laryngectomy means.
INCORRECT
The nurse needs to answer Mrs. Newman's question.
D) Reassure her that she will be able to sing with the band, but her voice may be different.
INCORRECT
This is a false statement.
The ONS has given verbal and written information to Mrs. Newman, answered any questions, and is completing the physical assessment.
6.
Which question is important for the nurse to ask Mrs. Newman?
A) "How much alcohol do you drink a week?"
CORRECT
Heavy drinking is a risk factor for laryngeal cancer but more importantly, if Mrs. Newman drinks large amounts of alcohol, the potential for withdrawal should be addressed.
B) "How long did you say you have you been singing with the band?"
INCORRECT
Voice abuse may be a risk factor but since laryngeal cancer has already been diagnosed, this would not be significant.
C) "When did you first notice any hoarseness in your voice?"
INCORRECT
Since laryngeal cancer has already been diagnosed, knowing when Mrs. Newman first noticed the hoarseness in her voice is not significant.
D) "What foods are difficult for you to swallow?"
INCORRECT
This would be pertinent information, but another question is more important to ask at this time.
Mrs. Newman reports that she drinks occasionally, mainly on the weekends with friends. The nurse is more concerned that Mrs. Newman smokes 1 pack of cigarettes a day. She discusses this issue with Mrs. Newman, who says, "Don't worry about my smoking. I will never smoke another cigarette again."
7.
How should the nurse respond to help Mrs. Newman in her attempt to stop smoking?
A) "You will not be able to smoke after your surgery."
INCORRECT
This statement does not help Mrs. Newman in her attempt to quit smoking. Additionally, some clients do continue smoking through the stoma site.
B) "What steps are you going to take to stop smoking?"
CORRECT
The nurse should determine what steps Mrs. Newman is planning to take to stop smoking and provide smoking cessation information, if needed.
C) "Does anyone else in your household smoke?"
INCORRECT
Another response is more likely to help Mrs. Newman in her attempt to quit smoking.
D) "I know it will be hard, and I am very proud of you."
INCORRECT
Although supportive, this statement is not the most helpful in supporting Mrs. Newman's attempt to stop smoking.
Multidisciplinary Team
Mrs. Newman discusses the surgery with her family and a woman from a laryngectomy support group. Mrs. Newman decides to go ahead and have the total laryngectomy.
8.
A referral to which member of the interdisciplinary team will be most important for Mrs. Newman prior to surgery?
A) Social worker.
INCORRECT
A social worker identifies support services and resources, including financial assistance. Although an important team member, the social worker is not the most important referral at this time.
B) Speech therapist.
CORRECT
Mrs. Newman will need to learn a new method of speech, which is taught by the speech therapist.
C) Case manager.
INCORRECT
A case manager assesses plans, coordinates care, and advocates for the client. Although an important team member, the CM is not the most important referral at this time.
D) Physical therapist.
INCORRECT
The PT helps the client achieve mobility. Although an important team member, the PT is not the most important referral at this time.
The speech therapist discusses with Mrs. Newman, alternative techniques for restoring her speech after the surgery. Selection of the best technique varies from person to person, depending on their age and personal preferences. Esophageal speech is popular among laryngectomees because it costs less and can provide a more normal sounding voice than some of the other options.
9.
Which statement describes esophageal speech?
A) Vibration and sound are used to form words by occluding a valve over the stoma.
INCORRECT
This is a description of tracheoesophageal fistula speech where a small one-way shunt valve is fitted into the fistula and occlusion of the valve forms words.
B) Swallowed air is used to create sound and words in a controlled belch.
CORRECT
This describes esophageal speech where clients "burp" swallowed air to form sounds into words using the palate, tongue, lips, and teeth.
C) A generator held to the neck creates vibrations that form words when the client speaks.
INCORRECT
This describes a type of electronic larynx.
D) A handheld device delivers tone via a plastic tube that is inserted into the mouth.
INCORRECT
This is another type of electronic speech generator.
After discussing her options with the speech therapist, Mrs. Newman demonstrates her ability to use esophageal speech. She comments, "I used to hear my son and his friends talk like this. Won't he be surprised!"
Preoperative Nursing Interventions
Two days later, Mrs. Newman is admitted to the hospital, accompanied by her husband and her 2 grown children. She is in the preoperative holding area.
10.
Which intervention will the nurse implement?
A) Reassure Mrs. Newman that her family can stay with her until surgery.
INCORRECT
Due to the limited space and the need to prepare the client for surgery, usually only one person is allowed to stay with the client in the holding area.
B) Ask Mrs. Newman if she has any concerns about the upcoming surgery.
INCORRECT
These concerns should have been addressed prior to admission.
C) Notify the surgeon that Mrs. Newman has been admitted to the hospital.
INCORRECT
The surgeon is aware of the time that Mrs. Newman is scheduled for surgery.
D) Determine if Mrs. Newman has any problems hearing or writing.
CORRECT
A means of communication must be determined prior to surgery since Mrs. Newman will not be able to speak following her total laryngectomy. An erasable communication board is usually used. If the client has trouble hearing or writing, this situation must be addressed and another means of communication determined.
Mrs. Newman shares with the nurse that she is worried that no one will help her if she needs help and that she will not be able to talk to anyone.
11.
Which intervention should the nurse implement?
A) Reassure Mrs. Newman that someone will be with her at all times.
INCORRECT
Someone may not be with her at all times.
B) Show her how to work the nurse's call light and have her perform a return demonstration.
INCORRECT
Knowing how to use the call light does not ensure that someone will answer it.
C) Provide a bell that she can ring as another means of communication.
CORRECT
A bell provides a means of empowerment for the client. It can be used to ring into the call light, the phone, or in the room to inform someone she needs something. It can also be used to answer questions: 1 ring for no or 2 rings for yes. The nurse should remember to ask Mrs. Newman "yes/no" questions (rather than open-ended) when she speaks to Mrs. Newman over the call light intercom.
D) Tell her that while her fears are justified, she should try not to worry.
INCORRECT
This is patronizing and does not address Mrs. Newman's concern.
PACU & ICU Postoperative Nursing Care
Following a 7-hour surgery, Mrs. Newman was first placed in the Post Anesthesia Care Unit (PACU) before being transferred to the Intensive Care Unit (ICU).
12.
Which nursing intervention should the ICU nurse implement?
A) Discourage coughing for the first 24 hours.
INCORRECT
Coughing should be encouraged to help remove secretions.
B) Support the head when moving the client in bed.
CORRECT
Head support reduces the strain on tissues in the operative area.
C) Place Mrs. Newman in the supine position with the bed flat.
INCORRECT
The head of the bed should be elevated to promote effective breathing.
D) Remove the tracheostomy tube every shift to assess the stoma site.
INCORRECT
The tracheostomy tube must be left in place until the stoma site has healed.
The nurse is completing the shift assessment and notes that Mrs. Newman has white and dark brown patchy areas on her tongue and oral mucosa.
13.
Which action should the nurse implement?
A) Document this finding and take no action.
CORRECT
With cancer of the larynx, the inside of the mouth and the tongue may appear white, gray, or dark brown and may display a patchy pattern.
B) Notify the healthcare provider during rounds.
INCORRECT
If the nurse thinks that medical intervention is required, the healthcare provider should be notified. The nurse should not wait until rounds to inform the healthcare provider of the change in status.
C) Determine when Mrs. Newman received her last antibiotic.
INCORRECT
In some situations, white patches in the mouth may indicate a superinfection. However, even if this were the case, knowing the time of the last dose of antibiotic is not useful information.
D) Assist Mrs. Newman to gargle with warm, salty water.
INCORRECT
Gargling will not help treat the patchy areas.
A Complication Occurs
Because of the cancer, Mrs. Newman is at risk for potential complications, such as neck wound fistula and a carotid artery blowout.
14.
When anticipating these possible complications, the nurse should place which equipment at Mrs. Newman's bedside?
A) The Intensive Care Unit crash cart.
INCORRECT
The ICU crash cart should remain centrally located for use with any of the clients in the Intensive Care Unit.
B) A syringe filled with calcium gluconate.
INCORRECT
This medication is not indicated for any complication that routinely occurs in a client with a total laryngectomy.
C) Several packages of sterile 4×4 gauze.
CORRECT
If a carotid artery blowout occurred, the nurse would need to apply direct pressure to stem the bleeding.
D) Two non-sterile hemostats.
INCORRECT
Non-sterile hemostats are often kept at the bedside of a client with chest tubes, but they are not needed following laryngectomy.
While assessing Mrs. Newman, the nurse notices that Mrs. Newman's blood pressure is 92/60, and her pulse is 112. Mrs. Newman reports feeling very tired.
15.
What action should the nurse implement first?
A) Suction Mrs. Newman's tracheostomy.
INCORRECT
This would be the first intervention if the client exhibited signs of ineffective airway clearance, but another intervention is warranted here.
B) Check Mrs. Newman's previous vital signs.
INCORRECT
Since the client’s vital signs reflect hypovolemic shock, another intervention has more immediacy than checking the former vital signs.
C) Administer oxygen via nasal cannula.
INCORRECT
Because Mrs. Newman does not breathe through her nose anymore, if oxygen is needed, a mask would be placed over the stoma site.
D) Slip a gloved hand under the client's neck.
CORRECT
Since Mrs. Newman's vital signs indicate possible hemorrhage, the nurse should assess for bleeding. A common site for blood to pool following any type of throat surgery is behind the client's neck.
The nurse also calls the nurse's station and requests a complete blood count (CBC) stat.
16.
In which case is the laboratory result consistent with blood loss through hemorrhaging?
A) Red blood cell count 5.2 million/mm3.
INCORRECT
Normal RBC count for a female is 4.0-5.3 million/mm3.
B) Hematocrit 40%.
INCORRECT
Normal hematocrit for a female is 36%-45%.
C) Hemoglobin 11.3 g/dl.
CORRECT
Normal hemoglobin for a female is 12.0 g/dl-15.0 g/dl. Therefore, 11.3 g/dl is consistent with blood loss through hemorrhaging.
D) Erythrocyte sedimentation rate 8 mm/hr.
INCORRECT
SED rate is not a laboratory test to diagnose hemorrhage. The normal SED rate for a female is 1-20 mm/hr.
The nurse's assessment reveals a small amount of old blood behind Mrs. Newman's neck. Since her hemoglobin is 11.3 g/dl the surgeon prescribes an IV fluid bolus. Mrs. Newman responds positively and no further bleeding occurs. The nurse's anticipation of potential complications and quick response avert further problems. The remainder of Mrs. Newman's post-anesthesia recovery progresses well, and she is transferred to the surgical unit.
Postoperative Nursing Care on the Surgical Unit
Mrs. Newman's gag reflex has returned, and she is preparing to eat her first meal.
17.
Which action should the nurse implement?
A) Remind her to place the food on the front of the tongue and flex her head backward to swallow.
INCORRECT
Food should be placed on the back of the tongue with the head flexed forward.
B) Provide Mrs. Newman with soft foods when eating for the first time after surgery.
CORRECT
Soft foods are easier to swallow initially.
C) Ensure the client has a variety of thin liquids to drink.
INCORRECT
Because liquids often cause the client to choke, all thin liquids should be thickened slightly.
D) Place cold packs around the client's neck prior to eating.
INCORRECT
Cold packs can decrease edema and constrict blood flow, but they are not helpful with swallowing or eating.
Mrs. Newman uses her erasable board to communicate to the staff that foods taste funny and that she cannot smell anything. She is worried that something is wrong.
18.
What action should the nurse take regarding Mrs. Newman's concern?
A) Notify the healthcare provider about this finding when making rounds.
INCORRECT
The healthcare provider does not need to be notified in this situation.
B) Have the client smell a variety of aromas to ensure that the client cannot smell.
INCORRECT
This action is inappropriate and may increase Mrs. Newman's anxiety.
C) Reassure the client that these senses will return after postoperative edema subsides.
INCORRECT
This offers false reassurance to the client.
D) Explain to the client that this is normal following this type of surgery.
CORRECT
This is a common, expected occurrence in clients with a total laryngectomy because a laryngectomy alters airflow, decreasing taste and smell perception. This information should be included in preoperative teaching, and it may need to be reinforced postoperatively as well.
Mrs. Newman has a tracheostomy that has an inner cannula. The nurse is performing routine tracheostomy care.
19.
Which action should the nurse implement first?
A) Cleanse the inner cannula using a small pipe brush.
INCORRECT
Although cleansing the inner cannula is part of routine trach care, it is not the first action that should be taken.
B) Pour hydrogen peroxide and normal saline into separate containers.
INCORRECT
Although these are the solutions used to cleanse the inner cannula, pouring them into separate containers is not the first action the nurse should take.
C) Wash the flange of the outer cannula with normal saline.
INCORRECT
This should be done after the inner cannula is reinserted into the outer cannula. However, it is not the first action the nurse should take.
D) Remove the tracheostomy dressing with clean disposable gloves.
CORRECT
The nurse should remove the dressing first, set up sterile supplies, clean the stoma site and outer cannula, then remove and clean the inner cannula before replacing it.
20.
What should the nurse do before reinserting the inner cannula?
A) Dry the outside of the inner cannula with non-sterile gauze.
INCORRECT
When cleaning the inner cannula, sterility must be maintained.
B) Clean it with hydrogen peroxide.
INCORRECT
The inner cannula should be rinsed thoroughly with normal saline before being reinserted into the outer cannula.
C) Remove the outer cannula, reinsert the inner cannula, then place back into stoma.
INCORRECT
The outer cannula should never be removed from the stoma site by the nurse.
D) Tap or shake the inner cannula to remove excess moisture.
CORRECT
This will help remove excess saline prior to inserting the cannula into the stoma in order to reduce the risk of fluid entering the lungs. Some sources recommend drying the inner cannula with sterile pipe cleaners, although this may damage the inner cannula. Follow the organization's policy and procedure.
Management Issues
An unlicensed assistive personnel (UAP) is assisting the surgical floor nurse with morning care for Mrs. Newman.
21.
Which task(s) should the nurse delegate to the UAP? (Select all that apply.)
A) Perform the routine tracheostomy care.
INCORRECT
Tracheostomy care is a sterile procedure. Because this level of care requires the expertise of a nurse, this task should not be delegated to a UAP.
B) Clean Mrs. Newman's bathroom.
INCORRECT
The housekeeping department should clean the bathroom, not the UAP.
C) Empty the Foley catheter and record the output.
CORRECT
This action may be delegated to the UAP. The nurse should follow up to assess if the output is adequate.
D) Change the intravenous bag on the pump.
INCORRECT
Intravenous fluids are considered medications. Medication administration cannot be delegated to a UAP.
E) Assist Mrs. Newman with her bed bath.
CORRECT
This action may be delegated to the UAP. The nurse should follow up to assess if there were any problems or concerns noted during the bed bath.
The charge nurse notices that the primary nurse caring for Mrs. Newman is cutting a 4 × 4 gauze to use as a tracheostomy dressing.
22.
Which action should the charge nurse implement?
A) Take no action since Mrs. Newman is the primary nurse's responsibility.
INCORRECT
Some action is required by the charge nurse.
B) Praise the primary nurse for using a cost-saving technique.
INCORRECT
Cost containment should not be at the expense of client safety.
C) Determine why commercially prepared dressings aren't being used.
INCORRECT
This can be done later, but the charge nurse must first correct the potentially dangerous situation.
D) Instruct the primary nurse not to cut gauze for the tracheostomy dressing.
CORRECT
Small strings from the gauze can be aspirated through the stoma into the lungs. Folding the gauze into a V-shape and placing it under the tracheostomy tube is an acceptable technique, but cutting the gauze is not.
Legal Considerations
The night nurse is preparing to administer the 12:00 midnight dose of gentamicin, an intravenous aminoglycoside antibiotic that was started when Mrs. Newman was in the PACU. The nurse notices the empty IV antibiotic bag that was administered during the day shift is labeled ampicillin. The nurse checks the Medication Administration Record and realizes the client does not have a prescription for ampicillin.
23.
Which action should the night nurse implement?
A) Call the day nurse to determine what occurred.
INCORRECT
The night nurse should not call the day nurse. The nurse will be notified the next day about the medication error.
B) Notify the pharmacist about the medication error.
INCORRECT
The pharmacist does not need to be notified of the medication error; the healthcare provider should be notified.
C) Complete a medication error incident report.
CORRECT
The night nurse should complete a medication error incident report to document this finding.
D) Assess Mrs. Newman's white blood cell count (WBC).
INCORRECT
The WBC count is important to determine the effectiveness of antibiotic therapy, but it does not address the medication error. Another intervention is more important.
The next time the nurse enters Mrs. Newman's room, Mrs. Newman writes on the communication board, "Is there something wrong? I heard someone in the hall say something about me receiving the wrong medication."
24.
How should the nurse respond?
A) "You were supposed to receive gentamicin, but you received ampicillin."
CORRECT
The best response by the nurse is to tell the truth.
B) "You are concerned that you might have received the wrong medication."
INCORRECT
Although this is a therapeutic response, it does not address Mrs. Newman's concern.
C) "Please don't worry about anything. I am sorry you overheard that conversation."
INCORRECT
This response does not address Mrs. Newman's concern.
D) "No, Mrs. Newman, you did not receive the wrong medication."
INCORRECT
Lying to the client is absolutely the wrong response for the nurse to make.
Mrs. Newman has no adverse effects from receiving the wrong antibiotic. The nurse responsible for the mistake and the risk manager are notified of the medication error the next morning.
Discharge Teaching
Mrs. Newman writes on the communication board that she is afraid of suffocating when she goes home since she has trouble coughing up the secretions from her lungs.
25.
Which instructions should the nurse provide to Mrs. Newman?
A) Take a deep breath in through the nose, cough, and expel the secretions through the tracheostomy.
INCORRECT
The client cannot breathe through her nose.
B) Insert a suction tube into the stoma while applying suction, then remove while twisting the tube.
INCORRECT
Suction should not be applied when inserting the tube, only when removing the tube.
C) Take a deep breath, occlude the tracheostomy with your finger, cough, and remove your finger.
CORRECT
This technique is called "glottal stop," which helps remove secretions.
D) Insert a small amount of sterile normal saline into the stoma and cough in a normal manner.
INCORRECT
The client should not insert liquid into the stoma since it goes directly into the lungs.
The nurse is discussing activities of daily living with Mrs. Newman.
26.
Which instruction should the nurse include?
A) Encourage Mrs. Newman to use aerosol deodorants.
INCORRECT
Aerosol deodorants should be discouraged since the spray could enter the stoma site.
B) Caution Mrs. Newman to take only tub baths.
CORRECT
Because water could enter the stoma site and go directly into the lungs during showers, tub baths should be encouraged.
C) Explain the need to wear a plastic bib when showering.
INCORRECT
The stoma site should be protected from water entering the site. Because a plastic bib could block the airway, the client should wear a shower shield if showering.
D) Advise Mrs. Newman not to wear any type of perfume.
INCORRECT
Mrs. Newman may wear perfume, but she should not apply it near the stoma site.
The nurse is completing discharge teaching.
27.
Which intervention has highest priority prior to discharge?
A) Stress the importance of returning to as normal a lifestyle as possible.
INCORRECT
This is a valuable intervention, but it does not have the highest priority.
B) Discuss the importance of attending support group meetings.
INCORRECT
Group support is important, but it is not the highest priority.
C) Encourage the client to wear attractive coverings over the stoma.
INCORRECT
Body image is important, but it is not the highest priority.
D) Ensure that Mrs. Newman carries a special identification card.
CORRECT
The card is available from the International Association of Laryngectomees and instructs the reader in providing an emergency airway or resuscitating someone with a stoma. Life-sustaining issues always have the highest priority.
Therapeutic Communication
Mrs. Newman is being discharged home tomorrow after 5 days in the hospital. Mr. Newman stops the nurse in the hallway and says that he is really scared about taking his wife home.
28.
What is the best response by the nurse?
A) "Let's sit down and discuss what you are worried about."
CORRECT
The nurse should attempt to find out what Mr. Newman is scared about and provide factual information, as well as support.
B) "It sounds like you can't take care of her."
INCORRECT
This response does not address Mr. Newman's fears and may make him defensive about his abilities as a caregiver.
C) "Have you discussed your fears with your wife?"
INCORRECT
This response does not address Mr. Newman's fears.
D) "I know that this must be very scary, but you and your wife are strong."
INCORRECT
This response does not address Mr. Newman's fears.
Mr. Newman hesitantly shares with the nurse that he is afraid to touch his wife.
29.
How should the nurse respond?
A) "You can touch your wife all you want. You will not hurt her."
INCORRECT
While this may be true, it blocks any further communication.
B) "Tell me more about what you mean by touching your wife."
CORRECT
The nurse needs to clarify exactly what Mr. Newman's fears are. If the nurse doesn't address his sexual concerns, it is unlikely that they will be addressed by another healthcare professional.
C) "Would you like to talk to your wife's doctor? I can call him for you."
INCORRECT
This response ignores Mr. Newman's concerns and shifts the responsibility to the physician. The nurse needs to address Mr. Newman's concerns directly.
D) "You are worried about touching your wife, but she needs your support right now."
INCORRECT
The nurse needs to address Mr. Newman's concerns and offer him support, rather than shifting the focus to his wife.
Discharged Home
A home healthcare nurse has been assigned to care for Mrs. Newman and is making the initial visit. After completing the admission assessment, the home healthcare nurse develops a nursing care plan for Mrs. Newman.
30.
Of the nursing diagnosis included in Mrs. Newman's care plan, which one has the highest priority?
A) Deficient knowledge.
INCORRECT
Knowledge deficit should always be addressed, but it is not the highest priority nursing diagnosis.
B) Impaired verbal communication.
INCORRECT
Despite preoperative preparation, communication may be a concern, but it is not the highest priority nursing diagnosis.
C) Risk of complicated grieving.
INCORRECT
The loss of speech is a major loss, but another nursing diagnosis has a higher priority.
D) Ineffective airway clearance.
CORRECT
One week following surgery, some local tissue edema may remain and may interfere with airway patency, therefore impaired airway clearance is the priority. In addition, secretions that may be difficult to remove may also affect airway patency. Remember Maslow's Hierarchy of Needs.
The home healthcare nurse is discussing the plan of care with Mrs. Newman and her husband. She instructs them to keep the rooms humidified at all times. Mr. Newman asks the nurse why this is important.
31.
Which explanation should the nurse provide?
A) The lower airway responsible for humidification was removed during surgery.
INCORRECT
The upper airway was removed, not the lower airway.
B) It will help decrease the amount of foreign material that enters the stoma.
INCORRECT
Humidification does not prevent foreign matter from entering the stoma.
C) Humidified air decreases the need for oral fluids.
INCORRECT
Oral fluids are a vital part of maintaining hydration of mucous membranes and secretions and should not be decreased, even when air in the home is humidified.
D) Humidified air will keep the mucous membranes and secretions moist.
CORRECT
With a tracheostomy, humidification of inspired air in the upper airway is lost. Humidifying the air helps maintain moist mucous membranes and secretions, which promotes secretion removal by coughing or suctioning.
Case Outcome
Mrs. Newman is adjusting to her new lifestyle. She and her husband are attending a laryngectomy support group weekly, her children see her frequently, and she enjoys visiting with friends that stop by. The speech therapist comes to her house twice a week, and her speech is slowly improving. She is planning to go to the country and western club in the near future. She has not had a cigarette since her surgery, but she takes 1 day at a time.
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