The nurse enters the room of a client who has just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems?
A)The nasogastric (NG) tube is disconnected from suction and clamped off.
B)The client is in a side-lying position with the head of the bed flat.
C)The Hemovac in the neck incision contains 200 mL of bloody drainage.
D)The client is coughing blood-tinged secretions from the tracheostomy.

Question

Quizplus · Accepted Answer

The client should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the Hemovac should be drained because the 200 mL of drainage will decrease the amount of suction in the Hemovac and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting.

The Nurse Enters the Room of a Client Who Has