A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action?

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Question 1 of 5

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action?

Correct Answer: A

Rationale: Bleeding is a critical postoperative risk; monitoring the incision is the priority in the first 24 hours.

Question 2 of 5

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?

Correct Answer: B

Rationale: Sudden shortness of breath in a bedridden patient suggests a possible pulmonary embolism, a life-threatening emergency requiring immediate assessment.

Question 3 of 5

The home health nurse is visiting a patient with chronic obstructive pulmonary disease (COPD). Which nursing action is appropriate to implement for a nursing diagnosis of impaired breathing pattern related to anxiety?

Correct Answer: B

Rationale: Pursed-lip breathing helps manage anxiety-related dyspnea by prolonging exhalation and reducing air trapping.

Question 4 of 5

A patient with cystic fibrosis (CF) has blood glucose levels that are consistently between 180 to 250 mg/dL. Which nursing action will the nurse plan to implement?

Correct Answer: C

Rationale: Elevated glucose in CF often indicates CFRD (CF-related diabetes), typically requiring insulin.

Question 5 of 5

What should the nurse do first when a patient's SpO2 drops to 85% during exercise?

Correct Answer: B

Rationale: The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental O2 when exercising. The other actions are also important, but the first action should be to correct the hypoxemia.

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