A nurse is caring for a patient who has had a total laryngectomy ...

[captainjonesify]

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?
 
  a. Monitor for bleeding.
  b. Maintain adequate IV fluid intake.
  c. Suction tracheostomy every eight hours.
  d. Keep the patient in semi-Fowler's position.

Question 2

The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider?
 
  a. Fever of 100.4 F (38 C)
  b. Diffuse crackles in the lungs
  c. Sore throat and frequent cough
  d. Myalgia and persistent headache

[blfontai]

Answer to Question 1

ANS: D
The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube.

Answer to Question 2

ANS: B
The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the-counter (OTC) pain relievers and increased fluid intake.

[captainjonesify]

Excellent

[ecabral0]

Gracias!