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
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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Related Questions
Correct Answer is D
Explanation
a. Position the client on the nonoperative side: The client should be positioned on the operative side to facilitate expansion of the remaining lung.
b. Monitor respiratory status every 8 hr: Postoperative respiratory status should be monitored more frequently than every 8 hours to assess for complications, especially in the initial
postoperative period.
c. Elevate the head of the bed to a 15° angle: The head of the bed should be elevated to a higher angle (usually 30-45 degrees) to promote optimal lung expansion and reduce the risk of
complications such as atelectasis.
d. Encourage the client to splint the incision when coughing: Encouraging the client to splint the incision when coughing helps minimize pain and supports effective coughing to prevent
complications such as atelectasis.
Correct Answer is D
Explanation
a. Position the client flat in bed: This position may increase pressure on the abdomen and exacerbate ascites. The head of the bed should be elevated to enhance respiratory function.
b. Weigh the client weekly: Weighing the client daily is more appropriate to monitor fluid retention and assess the effectiveness of interventions.
c. Medicate the client with acetaminophen for discomfort: While acetaminophen can be used for pain relief, its use should be monitored closely due to the potential for liver toxicity in clients with cirrhosis.
d. Measure the client’s abdominal girth every 8 hours: Monitoring abdominal girth is crucial for assessing the degree of ascites and evaluating the effectiveness of interventions.
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