A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:

Correct Answer: D

Rationale: The correct instruction for the client when removing secretions above the cuff of a tracheostomy tube is to exhale deeply as the nurse re-inflates the cuff. By having the client exhale deeply during cuff inflation, it helps to prevent aspiration of secretions or air into the lungs. This action also helps in securing an airtight seal around the tracheostomy tube before the normal breathing is resumed. It is crucial to promote the safety and prevent complications in clients with a tracheostomy tube, especially post partial laryngectomy.

Correct Answer: A

Rationale: Performing monthly breast self-examination (BSE) after menstruation is recommended because during this time, the breasts are less likely to be swollen or tender, which can help to ensure a more accurate examination. Engaging in BSE on a regular basis can help individuals become familiar with their breast tissue and better recognize any changes that may occur. By performing BSE monthly after menstruation, individuals can actively monitor their breast health and potentially detect any abnormalities or signs of breast cancer at an early stage.

Correct Answer: B

Rationale: When dehiscence, which is the separation of the layers of a surgical incision, occurs in a patient, it is important to have the patient lie down. This position will help decrease intra-abdominal pressure and reduce the risk of further complications. Having the patient sit upright in a chair can increase intra-abdominal pressure, worsening the dehiscence. Slowing IV fluids may be necessary to prevent fluid overload in certain situations, but it is not the immediate action required when dehiscence occurs. Obtain a sterile suture set may eventually be needed, but the priority in this situation is to stabilize the patient by having them lie down.

Correct Answer: A

Rationale: Monitoring a patient's weight is a crucial assessment in heart failure management. Sudden weight gain could indicate fluid retention, which is a common sign of worsening heart failure. By regularly monitoring the patient's weight, the nurse can detect early signs of fluid buildup and adjust the treatment plan accordingly. Weight monitoring is a simple yet effective way to assess the severity of heart failure and prevent complications. The other options (B. Appetite, C. Calorie count, D. Abdominal girth) are not as directly related to monitoring heart failure severity as weight measurement.

Correct Answer: B

Rationale: The correct answer is B. In the discharge teaching plan for a client after cardiac surgery, it is important for the nurse to include education on monitoring for signs of complications, such as notifying the physician if a painless lump is felt at the top of the chest incision. This could potentially indicate a seroma or hematoma, which may require medical attention. By educating the client on this specific point, the nurse helps to promote early detection and prompt management of any post-operative issues, which contributes to better outcomes for the client. The other options mentioned are important aspects of post-cardiac surgery care but do not address the specific concern of a painless lump at the chest incision site.