Question

The nurse enters the room of a patient 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? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________

a. The nasogastric (NG) tube is disconnected from suction and clamped off.
b. The patient 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 patient is coughing blood-tinged secretions from the tracheostomy

Answer 1

The nurse should prioritize the patient's care by addressing first the coughing of blood-tinged secretions, then the patient's side-lying position, followed by managing the Hemovac drainage, and lastly reattaching the NG tube to suction.

Step-by-step explanation:

When a patient returns from surgery for a total laryngectomy and radical neck dissection, a nurse must prioritize care based on the immediacy of threats to the patient's life and wellbeing. In this scenario, the nurse should address the problems in the following order:

1. Coughing blood-tinged secretions from the tracheostomy: This could indicate a potential airway compromise or bleeding, which are immediate threats to life.
2. The patient is in a side-lying position with the head of the bed flat: After extensive neck surgery, proper positioning is essential to facilitate breathing and prevent aspiration.
3. The Hemovac in the neck incision contains 200 mL of bloody drainage: This needs to be managed to avoid complications, but it is less immediately life-threatening than airway problems.
4. The NG tube is disconnected from suction and clamped off: While this requires attention to ensure nutrition and proper gastrointestinal function, it is the least acute of the issues presented.