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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Potassium level of 3.0 mEq/L: Hypokalemia is a potential adverse effect of digoxin, and a
potassium level of 3.0 mEq/L is below the normal range. Low potassium levels can increase the risk of digoxin toxicity.
b. Heart rate of 66/min: A heart rate of 66/min is within the normal range. Digoxin is used to
treat conditions like atrial fibrillation, and the heart rate should be within an appropriate range for the client's condition.
c. BP of 132/82 mm Hg: Blood pressure within the normal range does not require immediate reporting in the context of digoxin administration.
d. Digoxin level of 1.2 ng/ml: The digoxin level of 1.2 ng/ml is within the therapeutic range, and it does not require immediate reporting.
Correct Answer is B
Explanation
a. C-reactive protein: This is a marker of inflammation and is not specific to renal function. It is more commonly used to assess inflammation in various conditions.
b. Serum creatinine: Elevated levels of serum creatinine are indicative of impaired renal
function. Creatinine is a waste product that is normally filtered by the kidneys. Increased levels suggest decreased renal filtration.
c. Antinuclear antibody: This test is used to diagnose autoimmune diseases like SLE but does not directly measure renal function.
d. Erythrocyte sedimentation rate: This is a nonspecific marker of inflammation and is not directly related to renal function.
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