A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
Relieve the client's pain.
Promote oral hygiene
Ensure adequate nutrition
Prevent aspiration
The Correct Answer is D
A. Relieve the client's pain: While pain management is important for client comfort and recovery, it is not the priority immediately following intermaxillary fixation. Pain relief can be addressed once the more urgent concerns, such as preventing aspiration, are addressed.
B. Promote oral hygiene: Promoting oral hygiene is essential for preventing complications such as infection, but it is not the priority immediately after surgery and intermaxillary fixation. The client's airway and respiratory status should be the primary focus at this time.
C. Ensure adequate nutrition: Ensuring adequate nutrition is important for the client's overall recovery, but it is not the immediate priority after surgery and intermaxillary fixation. The priority is to prevent complications such as aspiration and maintain the client's airway.
D. Prevent aspiration: This is the priority action for the nurse. Intermaxillary fixation restricts the client's ability to open their mouth, increasing the risk of aspiration if vomiting occurs. The nurse should ensure that the client's airway is clear and that measures are in place to prevent aspiration, such as positioning the client appropriately and monitoring for signs of respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Erythema (redness) and edema (swelling) of the affected ear are classic signs of otitis media, an infection or inflammation of the middle ear. In otitis media, the middle ear becomes inflamed and fluid accumulates behind the eardrum, leading to redness and swelling of the tympanic membrane and surrounding tissues.
B. Tugging on the affected ear lobe is a common behavior observed in children with otitis media. Ear pulling or rubbing is often a sign of ear pain or discomfort, which can result from the pressure caused by the accumulation of fluid and inflammation in the middle ear.
C. Pain when manipulating the affected ear lobe is another common symptom of otitis media. Children with this condition may experience tenderness or discomfort when the affected ear is touched or manipulated due to the underlying inflammation and infection.
D. Clear drainage from the affected ear is not typically associated with otitis media. Instead, otitis media is characterized by the presence of middle ear effusion, which may manifest as fluid behind the eardrum. The drainage from otitis media is more commonly serous or purulent rather than clear.
Correct Answer is A
Explanation
A. Blood: The purpose of a stool guaiac test is to detect the presence of occult (hidden) blood in the stool. This test is commonly used to screen for gastrointestinal bleeding, which may indicate various conditions such as peptic ulcers, colorectal cancer, inflammatory bowel disease, or hemorrhoids. The guaiac test relies on the chemical reaction between guaiac resin and the heme component of hemoglobin in blood, resulting in a color change when blood is present in the stool.
B. Parasites: Stool tests for parasites typically involve examining stool samples under a microscope to identify the presence of parasitic organisms, such as protozoa or helminths. These tests are used to diagnose parasitic infections, such as giardiasis, cryptosporidiosis, or intestinal worms, rather than detecting blood in the stool.
C. Steatorrhea: Stool tests for steatorrhea assess the presence of excess fat in the stool, which may indicate malabsorption disorders, pancreatic insufficiency, or other gastrointestinal conditions affecting fat digestion and absorption. These tests involve analyzing stool samples for the presence of undigested fat globules rather than detecting blood.
D. Bacteria: Stool cultures are used to detect the presence of pathogenic bacteria in the stool, which may indicate bacterial infections such as Salmonella, Shigella, or Campylobacter. These tests involve culturing stool samples on specific media to identify bacterial pathogens rather than detecting blood. Stool guaiac tests specifically target the detection of occult blood and are not designed to identify bacteria in the stool.
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