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 D

Explanation

a. Turn the client so the cast will dry on all sides: While ensuring the cast is dry is important, the first priority following a surgical procedure is to assess neurovascular status to detect any

complications.

b. Remove the window and view the incision: Removing the window may compromise the cast's integrity, and the priority is to assess neurovascular status before inspecting the incision.

c. Medicate the client for pain: Pain management is important, but assessing neurovascular status is the initial priority to ensure there are no complications affecting circulation.

d. Perform neurovascular checks of the affected extremity: Neurovascular checks are the priority to detect any signs of impaired circulation or nerve function.

A. Weight gain B. Constipation C. Frequent mood changes D. Sensitivity to cold

Correct Answer is C

Explanation

a. Weight gain: Hyperthyroidism is more commonly associated with weight loss due to increased metabolism.

b. Constipation: Hyperthyroidism is more likely to cause diarrhea or increased bowel movements.

c. Frequent mood changes: Hyperthyroidism can lead to mood swings, irritability, and anxiety.

d. Sensitivity to cold: Sensitivity to cold is more commonly associated with hypothyroidism, not hyperthyroidism.

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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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