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 C

Explanation

a. Magnesium 1.9 mg: This magnesium level is within the expected reference range (1.3-2.1 mEq/L).

b. Chloride 99 mEq/L: This chloride level is within the expected reference range (98-106 mEq/L).

c. Sodium 126 mEq/L: A sodium level of 126 mEq/L is significantly below the normal range (135-145 mEq/L), indicating hyponatremia, which can have serious consequences and requires prompt attention.

d. Potassium 3.6 mEq/L: This potassium level is within the expected reference range (3.5-5.0 mEq/L).

A. Begin oxygen therapy. B. Start an IV infusion of lactated Ringer’s. C. Initiate cardiac monitoring. D. Administer IV morphine.

Correct Answer is A

Explanation

a. Begin oxygen therapy: Oxygen therapy is the priority intervention for a client with a pulmonary embolism to improve oxygenation and prevent hypoxemia.

b. Start an IV infusion of lactated Ringer’s: While fluid resuscitation may be needed, oxygen therapy takes precedence to address the immediate respiratory compromise.

c. Initiate cardiac monitoring: Cardiac monitoring is important, but addressing oxygenation is the priority in a client with a pulmonary embolism.

d. Administer IV morphine: Pain management may be necessary, but the priority is to address the respiratory distress and potential hypoxemia associated with a pulmonary embolism.

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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

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