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. Instruct the client to place his chin to his chest and swallow: This technique helps facilitate the passage of the nasogastric tube through the pharynx and into the esophagus.

b. Withdraw the tube if the client gags during insertion: Gagging is a normal response, and

withdrawing the tube may lead to repeated attempts and discomfort for the client. Encouraging the client to swallow can help overcome the gag reflex.

c. Place the client in a supine position: The client is usually positioned in a semi-Fowler's position or upright to ease tube insertion and minimize the risk of aspiration.

d. Measure the tube for insertion from the tip of the nose to the umbilicus: The proper

measurement for nasogastric tube insertion is typically from the tip of the nose to the earlobe and then down to the xiphoid process, not the umbilicus.

A. Eating dinner early in the evening B. Sleeping on a large wedge-style pillow C. Consuming low-fat meats D. Drinking orange juice regularly

Correct Answer is D

Explanation

a. Eating dinner early in the evening: Eating dinner early can actually be a positive factor in preventing heartburn by allowing more time for digestion before lying down.

b. Sleeping on a large wedge-style pillow: Elevating the upper body can help prevent acid reflux, so sleeping on a wedge-style pillow may be a helpful strategy.

c. Consuming low-fat meats: Low-fat meats are less likely to contribute to heartburn compared to high-fat meats.

d. Drinking orange juice regularly: Orange juice is acidic and can contribute to heartburn,

especially if consumed regularly. The acid content can irritate the esophagus and worsen GERD symptoms.

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