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Exam NCLEX-RN topic 4 question 65 discussion

Actual exam question from Test Prep's NCLEX-RN
Question #: 65
Topic #: 4
[All NCLEX-RN Questions]

A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:

  • A. Activity intolerance
  • B. Ineffective airway clearance
  • C. High risk for infection
  • D. Altered oral mucous membrane
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Suggested Answer: B 🗳️
(A) The laryngectomy client should be able to gradually increase activities without difficulty. (B) The laryngectomy client may have copious amounts of secretions and require suctioning for the first 2448 hours. The cannula will require cleaning even after the first 24 hours because mucus collects in it. (C) The client does have a potential for infection, but it is not a more importantnursing priority than the ineffective airway clearance. (D) This problem is not a more important nursing priority than ineffective airway clearance. The clients mouth may become dry, but good oral care should take care of the dryness.

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