A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

Assess for signs of infection.

Assess for a patent airway.

Assess ability to clear oral secretions.

Assess for ability to communicate.

Answer and Explanation

The Correct Answer is B

Choice A reason:

While assessing for signs of infection is important, ensuring a patent airway takes precedence immediately following surgery.

Choice B reason:

This statement is correct. Assessing for a patent airway is the top priority in postoperative care to ensure the patient can breathe effectively.

Choice C reason:

Assessing the ability to clear oral secretions is important, but it is secondary to ensuring a patent airway.

Choice D reason:

Assessing the ability to communicate is important, but it is not the immediate priority after surgical resection for oropharyngeal cancer.

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Correct Answer is C

Explanation

Choice A reason:

A shiny, moist stoma is generally a healthy sign, indicating good blood supply and adequate hydration of the stoma tissue. It is not a cause for concern.

Choice B reason:

A rosebud-like stoma orifice is a normal appearance for some types of stomas. It indicates a healthy stoma with good blood supply. This finding is expected and does not warrant concern.

Choice C reason:

A purplish-colored stoma may indicate compromised blood supply to the stoma, which is a serious concern and should be reported to the provider promptly. It may suggest inadequate blood flow to the stoma, which could lead to tissue necrosis.

Choice D reason:

Stoma oozing red drainage may be normal immediately postoperatively. It can be due to some oozing from the surgical site, and if it's minimal and stops after a short while, it's generally not a cause for concern.

A. Keep the patient in a low Fowler's position when at rest. B. Connect the tube to continuous wall suction when not in use. C. Confirm placement of the tube prior to each medication administration. D. Have the patient sip cool water to stimulate saliva production.

Correct Answer is C

Explanation

Choice A reason:

Keeping the patient in a low Fowler's position may not directly address the management of the NG tube and dysphagia.

Choice B reason:

Connecting the tube to continuous wall suction when not in use is not a standard intervention for NG tube feeding.

Choice C reason:

This statement is correct. Confirming placement of the tube prior to each medication

administration is crucial to ensure safe and effective delivery of medications and nutrition.

Choice D reason:

Having the patient sip cool water, while a general recommendation for some patients, does not specifically address the care of the NG tube.

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A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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