The nurse is caring for a client who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery, which of the following actions is priority?
A)Monitor for bleeding.
B)Assess breath sounds.
C)Clean the inner cannula every 8 hours.
D)Avoid changing the tracheostomy ties.

Question

Quizplus · Accepted Answer

The most important goals posttracheotomy are to maintain the airway and ensure adequate oxygenation. Assessment of the breath sounds is the priority action. Maintenance of the tracheostomy ties, cleaning the inner cannula, and checking for bleeding also are appropriate nursing actions but are not of as high a priority.

The Nurse Is Caring for a Client Who Has Had