A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period?
Ineffective airway clearance related to thick, copious secretions
Malnourishment related to NPO status and dysphagia
High risk for infection related to surgical incisions
Impaired verbal communication related to the tracheostomy
The Correct Answer is A
a. Ineffective airway clearance: This is the priority as it addresses the immediate threat to the client's respiratory status. Accumulation of thick, copious secretions can lead to airway
obstruction and respiratory distress.
b. Malnourishment: While important, addressing malnourishment is not an immediate
postoperative priority. The client may receive nutrition through alternative means until normal swallowing function is restored.
c. High risk for infection: Infection is a concern, but ensuring airway clearance takes precedence in the immediate postoperative period.
d. Impaired verbal communication: Verbal communication is important, but it is not as immediate a concern as ensuring the airway is clear to prevent respiratory compromise.
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Related Questions
Correct Answer is B
Explanation
a. Rest in a supine position: Resting in a supine position may compromise lung expansion, and an upright position is often recommended for clients with emphysema to improve ventilation.
b. Breathe in through her nose and out through pursed lips: This technique helps maintain
positive airway pressure, preventing premature airway collapse, and can improve gas exchange in clients with emphysema.
c. Limit fluid intake throughout the day: Adequate hydration is important for maintaining
respiratory secretions in a liquefied state and is generally encouraged for clients with respiratory conditions.
d. Consume a low-protein diet: A low-protein diet is not specifically indicated for improving gas exchange in clients with emphysema. Nutrition recommendations may focus on a well-balanced diet to support overall health.
Correct Answer is D
Explanation
a. Emesis of 100 mL: While emesis is a concern, the priority is to address potential complications related to the surgical procedure first.
b. Oral temperature of 37.5" C (99.5° F): This temperature is within a normal range, and it is not an immediate concern.
c. Pain level of 4 on a 0 to 10 rating scale: Pain is important to address, but the priority is to assess for potential complications such as bleeding or infection.
d. Thick, red-colored urine: This finding suggests the possibility of bleeding, which could be a complication of the TURP procedure. It is the priority finding to report to the provider for further evaluation.
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