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

Answer and Explanation

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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Correct Answer is A

Explanation

a. Determine the patency of the tubing: The first action should be to assess for any obstruction or kinks in the tubing. A blockage may be preventing the flow of urine.

b. Notify the provider: While notifying the provider may be necessary, assessing the tubing for patency is a more immediate action.

c. Offer oral fluids: While hydration is important, the priority is to ensure that the urinary catheter is functioning properly.

d. Administer a prescribed analgesic: Pain management is important postoperatively, but the

immediate concern is the lack of urinary output, which requires assessment and intervention to rule out catheter obstruction.

A. Bradycardia B. Anemia C. Hypokalemia D. Neutropenia

Correct Answer is A

Explanation

a. Bradycardia: Atenolol is a beta-blocker that can slow down the heart rate, leading to

bradycardia. Monitoring the client for signs of bradycardia, such as dizziness, fatigue, or fainting, is important.

b. Anemia: Atenolol is not known to cause anemia. Monitoring for anemia is not a specific concern with this medication.

c. Hypokalemia: Atenolol is not associated with causing hypokalemia. However, beta-blockers in general may affect potassium levels indirectly.

d. Neutropenia: Atenolol is not typically associated with causing neutropenia. Monitoring for neutropenia is not a specific concern with this medication.

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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?

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