Question

A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?

a. Teach the client alternative methods of communication, such as using a communication board.
b. Administer pain medication to keep the client comfortable.
c. Encourage the client to write down their needs and concerns.
d. Assess the client's respiratory status and airway patency.

Answer 1

The first action the nurse should take is to assess the client's respiratory status and airway patency, as airway management is the top priority postoperatively, especially after a laryngectomy.

Step-by-step explanation:

The nurse is updating the plan of care for a client who is 48 hours postoperative following a laryngectomy and cannot speak. The question asks which action the nurse should plan to take first. Given the context of postoperative care and considering the principles of airway management, the first action should be to assess the client's respiratory status and airway patency. This is crucial as the airway and breathing are the top priorities in postoperative care, especially following surgeries that can impact the airway, such as a laryngectomy. After ensuring that the client has a patent airway and is breathing adequately, the nurse can then address other needs such as pain management, which often includes administering pain medication, and communication with the client, which can involve teaching alternative methods such as using a communication board or encouraging the client to write down their needs and concerns. However, these actions come after confirming the stability of vital functions like respiration.