A postoperative priority nursing diagnosis for a client having a vertical partial laryngectomy would be:

Correct Answer: B

Rationale: The laryngectomy client should be able to gradually increase activities without difficulty. The laryngectomy client may have copious amounts of secretions, which will require suctioning for the first 24-48 hours. Because the mucous collects in the cannula, it will require cleaning after the first 24 hours. Even though the client does have a potential for infection, this is not more important than the ineffective airway clearance. An altered mucous membrane problem is not more important than ineffective airway clearance. The client's mouth may become dry, but can be taken care of with good oral care.

Correct Answer: D

Rationale: A preoperative assessment should include the patient's history, but the focus should be particularly on his expectations of this particular hospitalization. Knowledge about whether he received his childhood immunizations is important, but his reactions to those, even if he knows what they were, is not the most important information to gain today. The type of diet he's on is good information, but again not the most important information listed here. It is vital to determine the patient's expectations of his surgery, in order to correct any misperceptions he may have about the outcome, or reason, for this invasive treatment.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D, the homeless person with altered mental status, poor muscle coordination, and hot, dry, ashen skin. This patient is likely experiencing severe dehydration and hyperthermia, which are life-threatening conditions requiring immediate attention. Dehydration can lead to electrolyte imbalances and organ failure, while hyperthermia can progress to heat stroke. Option A, the elderly person with dizziness and syncope after sun exposure, may have heat exhaustion, but the symptoms in option D indicate a more critical condition. Option B, the marathon runner with leg cramps and other symptoms, likely has heat exhaustion, which is serious but not as immediately life-threatening as the conditions in option D. Option C, the homemaker with signs of heat exhaustion due to a broken air conditioner, also requires attention but is not as critical as the altered mental status and poor coordination seen in option D. In the context of medical-surgical nursing, it is essential to prioritize patients based on the severity and acuity of their conditions. This question highlights the importance of recognizing critical signs and symptoms that require immediate intervention to prevent further deterioration and potential life-threatening outcomes. Nurses must be able to quickly assess and prioritize patients based on the urgency of their needs to provide timely and appropriate care.

Correct Answer: C

Rationale: In the context of medical-surgical nursing practice, the most appropriate task for an LPN/LVN is to provide emotional support and supportive communication, which is option C. This is because LPNs/LVNs are trained to deliver holistic care to patients, which includes addressing their emotional well-being and providing psychological support during times of distress or uncertainty. LPNs/LVNs have the skills to engage in therapeutic communication and offer empathy to patients in need. Option A, assessing immediate emotional state and physical injuries, is typically within the scope of practice of a registered nurse or advanced practice nurse who has the training and licensure to perform comprehensive assessments and make clinical judgments. Option B, collecting forensic evidence like hair samples and saliva swabs, requires specialized training and is usually carried out by forensic nurses or trained technicians. Option D, ensuring the 'chain of custody' is maintained, is a legal and procedural task that is often the responsibility of law enforcement personnel or individuals specifically trained in forensic protocols. LPNs/LVNs are not typically involved in maintaining the chain of custody in a healthcare setting. In an educational context, it is important for nursing students to understand the scope of practice for different levels of nursing personnel. By selecting option C as the most appropriate task for an LPN/LVN, students can grasp the importance of providing holistic care and emotional support as integral components of nursing practice. This question reinforces the need for clear understanding of roles and responsibilities within the healthcare team.

Correct Answer: C

Rationale: In the context of medical-surgical nursing, delegating tasks appropriately is crucial for optimal patient care. The most appropriate task to delegate to a nursing assistant among the options provided is "Assist with postmortem care (Option C)." This task involves non-invasive care after a patient has passed away and can be safely and effectively performed by a nursing assistant under the supervision of a registered nurse. Option A, escorting the family to a place of privacy, requires sensitivity, communication skills, and potentially providing emotional support to the family members. This task is more suited for a registered nurse who has the training and expertise to handle such delicate situations effectively. Option B, going with the organ donor specialist to talk to the family, involves complex discussions about organ donation that require specialized knowledge and training. This task should be handled by a healthcare professional with specific expertise in organ donation and counseling. Option D, assisting the family to collect belongings, also involves emotional support and sensitivity, as well as potential interactions that may require medical knowledge. This task is best performed by a healthcare professional who can address any medical concerns or emotional needs that may arise during the process. Educationally, understanding the principles of delegation in nursing is essential for providing safe and effective care. Nurses must consider factors such as the complexity of the task, the skills and training of the assistive personnel, and the needs of the patient and family when delegating responsibilities. By selecting the appropriate tasks for delegation, healthcare providers can optimize teamwork, efficiency, and patient outcomes.