What is the priority goal after a laryngectomy and radical neck dissection?

Correct Answer: C

Rationale: The priority goal after a laryngectomy and radical neck dissection is to maintain an open airway (Option C). This is crucial for ensuring proper oxygenation and ventilation for the patient. In this specific procedure, where the larynx is removed and extensive neck dissection is performed, airway management is paramount due to the potential for airway compromise from edema, secretions, or bleeding. Option A, monitoring for bleeding, is important but is not the priority immediately postoperatively. Bleeding can be managed once the airway is secured. Option B, maintaining IV fluids, is important for hydration and electrolyte balance but does not address the immediate need for airway management. Option D, suctioning frequently, is not the priority as it may increase the risk of trauma to the surgical site and exacerbate edema. In an educational context, understanding the hierarchy of patient care priorities post laryngectomy and radical neck dissection is crucial for nursing students and healthcare professionals. Emphasizing the significance of airway management in these cases highlights the critical thinking and quick decision-making skills required in managing complex patient situations. Prioritizing patient safety and physiological needs is foundational in nursing practice and ensures optimal patient outcomes in high-risk situations.

Correct Answer: B

Rationale: The correct answer is B) Pulmonary embolism. In a patient on bed rest with sudden shortness of breath, the immediate assessment of a pulmonary embolism is crucial. This is because immobility can lead to the formation of deep vein thrombosis (DVT), which can then result in a pulmonary embolism when a blood clot dislodges and travels to the lungs. Option A) Pneumonia is incorrect because it typically presents with a slower onset of symptoms such as fever, cough, and sputum production. Option C) Asthma is unlikely in a patient on bed rest without a history of asthma, and it would not typically present suddenly in this context. Option D) Heart failure may present with shortness of breath, but the sudden onset in a patient on bed rest makes pulmonary embolism a more immediate concern. Educationally, understanding the high-risk factors for conditions like DVT and pulmonary embolism in immobilized patients is essential for nurses. Recognizing the sudden onset of symptoms and knowing the appropriate actions to take can be life-saving. This question highlights the importance of quick and accurate assessment in clinical practice to ensure timely intervention and optimal patient outcomes.

Correct Answer: C

Rationale: The correct answer is C) Eat small amounts frequently. Patients with COPD often struggle with maintaining adequate nutrition due to symptoms such as increased work of breathing, fatigue, and feelings of fullness. Eating smaller, more frequent meals can help these patients meet their caloric needs by reducing the energy expenditure required for digestion and decreasing the sensation of fullness that can accompany larger meals. This approach allows for a more manageable intake of food throughout the day, ensuring that the patient receives the necessary nutrients without feeling overwhelmed. Option A) Eat large meals is incorrect because large meals can exacerbate symptoms of COPD by causing increased fatigue and feelings of fullness, making it difficult for patients to consume an adequate amount of calories. Option B) Rest after meals is incorrect because while resting before meals can help conserve energy for eating, resting after meals does not specifically address the issue of caloric intake for patients with COPD. Option D) Avoid protein is incorrect because protein is an essential nutrient for maintaining muscle mass and overall health, especially for individuals with COPD who may experience muscle wasting and weakness. Restricting protein intake could further compromise their nutritional status. Educationally, it is crucial for healthcare providers to understand the unique nutritional challenges faced by patients with COPD and to provide tailored guidance on how to optimize their caloric intake. By explaining the rationale behind the correct answer and highlighting the implications of the incorrect options, educators can help reinforce the importance of individualized dietary strategies in managing COPD effectively.

Correct Answer: C

Rationale: The correct answer is C) Use of accessory muscles because this symptom indicates that the patient is in severe respiratory distress. When a patient is using accessory muscles to breathe, it means that their respiratory effort is compromised, and they are struggling to maintain adequate oxygenation. This is a critical sign that warrants immediate intervention to support the patient's breathing and prevent further deterioration. Wheezing (A) and coughing (B) are common respiratory symptoms that can occur in various respiratory conditions, but they do not necessarily indicate a need for rapid intervention. These symptoms may suggest underlying respiratory issues that require assessment and management but do not signify the same level of urgency as the use of accessory muscles. Fatigue (D) is a vague symptom that can be present in many conditions and may not specifically point to respiratory distress. While fatigue can be a sign of respiratory compromise in some cases, it is not as indicative of immediate need for intervention as the visible use of accessory muscles. In an educational context, understanding the significance of different respiratory symptoms is crucial for nurses and healthcare providers to prioritize care effectively. Recognizing the specific signs of respiratory distress that require rapid intervention can help prevent complications and improve patient outcomes. This question highlights the importance of clinical assessment skills and prompt decision-making in managing patients with respiratory compromise.

Correct Answer: A

Rationale: The correct answer is A) It is a colorless, odorless gas. This is because oxygen, in its natural state, is a gas that is invisible, has no distinct smell, and is tasteless. Oxygen is a vital component of the air we breathe and plays a crucial role in the process of respiration in living organisms. Option B) It is a bright red liquid is incorrect because oxygen is a gas at room temperature and pressure. While liquid oxygen does exist, it is not bright red but rather blue when in its liquid state. Option C) It is a highly conductive solid is incorrect because oxygen is not typically found in a solid state under normal conditions. Oxygen is a gas at room temperature and pressure. Option D) It dissolves easily in water is incorrect because oxygen is actually poorly soluble in water. While oxygen can dissolve in water to some extent, it is not considered highly soluble. Understanding the physical properties of oxygen is essential for healthcare professionals, especially nurses, as they work with patients who may require supplemental oxygen therapy. Knowing that oxygen is a colorless, odorless gas helps nurses in properly assessing and administering oxygen therapy to patients in need. This knowledge is crucial for providing safe and effective care, as well as understanding the physiological processes related to oxygenation in the human body.