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 B
Explanation
a. “I will wait 10 min between each inhalation.”: There is no need to wait 10 minutes between
inhalations of albuterol. The usual recommendation is to wait 1-2 minutes if a second inhalation is needed.
b. “I will hold my breath at least 10 seconds after inhaling the medication.”: Holding the breath for at least 10 seconds after inhaling helps ensure that the medication reaches the lower airways and is absorbed effectively.
c. “I will tilt my head forward while inhaling the medication.”: Tilted head position is not necessary for using an inhaler; a proper inhalation technique is more critical.
d. “I will hold the inhaler with my non-dominant hand.”: The hand used to hold the inhaler is not as crucial as proper inhalation technique, but using the dominant hand may be more comfortable for most individuals.
Correct Answer is A
Explanation
a. Instruct the client to place his chin to his chest and swallow: This technique helps facilitate the passage of the nasogastric tube through the pharynx and into the esophagus.
b. Withdraw the tube if the client gags during insertion: Gagging is a normal response, and
withdrawing the tube may lead to repeated attempts and discomfort for the client. Encouraging the client to swallow can help overcome the gag reflex.
c. Place the client in a supine position: The client is usually positioned in a semi-Fowler's position or upright to ease tube insertion and minimize the risk of aspiration.
d. Measure the tube for insertion from the tip of the nose to the umbilicus: The proper
measurement for nasogastric tube insertion is typically from the tip of the nose to the earlobe and then down to the xiphoid process, not the umbilicus.
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