when preparing a client who has had a total laryngectomy for discharge what instruction is most important for the nurse to include in the discharge te
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HESI RN

HESI Medical Surgical Practice Exam Quizlet

1. When preparing a client who has had a total laryngectomy for discharge, what instruction is most important for the nurse to include in the discharge teaching?

Correct answer: C

Rationale: The most crucial instruction for a client who has had a total laryngectomy is to carry a medic alert card stating that they are a total neck breather. This is important because if they experience a cardiac arrest, mouth-to-neck breathing may be required. Choice A about carrying suction equipment is not the most critical as the client may not always need it. Choice B is not as essential as having a medic alert card. Choice D is not directly related to the client's safety due to their laryngectomy.

2. The healthcare provider is assessing a client undergoing peritoneal dialysis. Which of the following findings should be reported immediately to the physician?

Correct answer: C

Rationale: Cloudy dialysate outflow should be reported immediately to the physician as it is a concerning sign of peritonitis, a severe infection of the peritoneum. Peritonitis is a serious complication of peritoneal dialysis that requires prompt medical intervention to prevent further complications. Clear dialysate outflow and inflow are normal findings in peritoneal dialysis and do not indicate an immediate need for intervention. Increased blood pressure, while important to monitor, is not directly related to peritoneal dialysis and would not be the priority over the potentially life-threatening complication of peritonitis.

3. A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

Correct answer: D

Rationale: During the diuretic phase of acute kidney injury (AKI), monitoring for hypovolemia and electrocardiographic (ECG) changes is crucial. Hypovolemia can occur due to the increased urine output in this phase, potentially leading to dehydration and electrolyte imbalances. Electrolyte imbalances can result in ECG changes, such as arrhythmias, which can be life-threatening. Therefore, careful monitoring of fluid status and ECG findings helps in preventing complications. Choices A, B, and C are not the most crucial parameters to monitor during the diuretic phase of AKI. Side effects of total parenteral nutrition (TPN) and Intralipids, uremic irritation of mucous membranes and skin surfaces, and elevated creatinine and blood urea nitrogen (BUN) are important considerations in other phases of AKI or in other conditions, but they are not the primary focus during the diuretic phase when hypovolemia and ECG changes take precedence.

4. A healthcare professional is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which of the following coexisting problems is cause for the healthcare professional to suspect that the oxygen saturation readings are not entirely accurate?

Correct answer: C

Rationale: Low blood pressure (hypotension), shock, and the use of peripheral vasoconstricting medications can lead to inaccurate pulse oximetry readings due to impaired peripheral perfusion. Hypertension and infection are not typically associated with inaccurate pulse oximetry readings, while the loss of cough reflex does not directly affect oxygen saturation readings.

5. The client with diabetes mellitus should be cautioned by the nurse taking a sulfonylurea that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following?

Correct answer: D

Rationale: The correct answer is D: Disulfiram (Antabuse)-like symptoms. When a client with diabetes mellitus taking a sulfonylurea consumes alcohol, it can lead to disulfiram-like symptoms, such as nausea, flushing, and palpitations. Choice A, hypokalemia, is incorrect because sulfonylureas do not typically lead to low potassium levels. Choice B, hyperkalemia, is incorrect as sulfonylureas are not associated with high potassium levels. Choice C, hypocalcemia, is also incorrect because sulfonylureas are not known to cause low calcium levels.

Similar Questions

A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client?
The client with peripheral artery disease has been prescribed clopidogrel (Plavix). The nurse understands that more teaching is necessary when the client states which of the following?
The healthcare provider is unable to palpate the client's left pedal pulses. Which of the following actions should the healthcare provider take next?
A client is receiving continuous ambulatory peritoneal dialysis. Which of the following statements indicates the need for more teaching by the nurse?
The nurse is monitoring a client with chronic renal failure who is receiving hemodialysis. The nurse should report which of the following findings immediately?

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