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. 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.

A. A client taking furosemide for chronic hypertension. B. A client taking a potassium supplement twice a day. C. A client taking aluminum hydroxide for gastric upset. D. A client taking chlorpropamide for type 2 diabetes mellitus.

Correct Answer is A

Explanation

a. A client taking furosemide for chronic hypertension: Furosemide is a loop diuretic that can

lead to hypokalemia, which increases the risk of digoxin toxicity, as hypokalemia potentiates the effects of digoxin on the heart.

b. A client taking a potassium supplement twice a day: Potassium supplementation reduces the risk of digoxin toxicity, as hypokalemia is a risk factor for toxicity.

c. A client taking aluminum hydroxide for gastric upset: Aluminum hydroxide is an antacid and does not significantly affect digoxin levels.

d. A client taking chlorpropamide for type 2 diabetes mellitus: Chlorpropamide is an oral hypoglycemic agent and does not significantly affect digoxin levels.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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