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. Three to seven days after menses stops: Performing BSE a few days after menstruation allows the breasts to return to a more baseline state, reducing the influence of hormonal changes on

breast tissue.

b. On the same day every month: Hormonal changes during the menstrual cycle can affect breast tissue, and performing BSE on the same day every month may not provide consistent conditions for examination.

c. Prior to the beginning of menses: Hormonal changes before menstruation can lead to breast tenderness and changes, potentially affecting the accuracy of the examination.

d. On the second day of menstruation: Hormonal changes and potential breast tenderness during the early days of menstruation may not be the optimal time for BSE.

A. "Use the provided towelette to cleanse the area by moving in a back-and-forth motion." B. "It will be easier to use your nondominant hand to spread the labia." C. "Start the flow of urine before passing the container under the stream to collect the specimen." D. "Remove the specimen container before stopping the stream of urine"

Correct Answer is A

Explanation

Choice A Rationale: The correct method for cleansing the area before collecting a midstream urine specimen is to wipe from front to back, not back-and-forth. This is to avoid contamination of the specimen with bacteria from the anal area. The towelette should be used in a single stroke and then discarded to ensure cleanliness.

Choice B Rationale: Using the nondominant hand to spread the labia is a standard practice that allows the dominant hand to manipulate the collection container. This technique helps to prevent contamination of the specimen by keeping the container away from the body and ensuring a clean catch.

Choice C Rationale: It is important to start the flow of urine before collecting the specimen to ensure that the 'midstream' urine is captured. This helps to flush out any bacteria that may be present at the opening of the urethra, reducing the risk of contaminating the sample.

Choice D Rationale: The specimen container should be removed from the stream before stopping the flow of urine to avoid contamination. The initial and final parts of the urine stream can carry bacteria from the urethra and skin, so only the midstream should be collected in the container.

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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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A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times?

Correct Answer is A

Explanation

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Explanation

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