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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Liver function tests: While lithium can affect liver function in some cases, routine liver function tests are not typically required before administering lithium. These tests are more relevant for medications metabolized by the liver.
B. Thyroid hormone assay: This is the correct action. Regular monitoring of thyroid function, including thyroid hormone levels, is essential for clients taking lithium, as lithium therapy can lead to hypothyroidism or exacerbate preexisting thyroid conditions. Checking thyroid function before administering lithium helps ensure the client's thyroid status is within the therapeutic range and identifies any abnormalities that may require intervention.
C. Erythrocyte sedimentation rate (ESR): ESR is a nonspecific marker of inflammation and is not directly relevant to monitoring lithium therapy. While lithium can affect renal function and electrolyte balance, ESR does not specifically assess these parameters.
D. Brain natriuretic peptide (BNP): BNP is a marker of cardiac function and is not routinely monitored in clients taking lithium. While lithium can have cardiovascular effects, routine BNP testing is not necessary before administering lithium. Monitoring for cardiovascular side effects of lithium typically involves assessing for symptoms such as arrhythmias or changes in blood pressure and heart rate.

A. Administer ibuprofen as needed for pein B. Encourage the parents to rock the infant C. Offer the infant a pacifier. D. Position the infant on her abdomen

Correct Answer is B

Explanation

Rationale:

A) Administer ibuprofen as needed for pain: Ibuprofen is not typically recommended for pain relief in infants under 6 months old due to the risk of adverse effects, such as gastrointestinal irritation and renal impairment. Additionally, surgical repair of a cleft lip is not typically associated with severe postoperative pain requiring ibuprofen in infants.

B) Encourage the parents to rock the infant: This is the correct intervention. Rocking or gentle movement can provide comfort to infants postoperatively and may help soothe them. It can also promote bonding between the infant and parents, which is important for emotional support during the recovery period.

C) Offer the infant a pacifier: Pacifiers can be soothing for infants and may help provide non-nutritive sucking comfort. However, it's essential to ensure that the pacifier does not interfere with wound healing or exacerbate discomfort related to the cleft lip repair. Therefore, while offering a pacifier may be appropriate, it should be done with caution and under the guidance of the surgical team.

D) Position the infant on her abdomen: Placing the infant on her abdomen (prone position) is not recommended postoperatively, especially after cleft lip repair surgery. The supine position is typically preferred to reduce the risk of aspiration and ensure adequate airway patency. Additionally, the prone position may put pressure on the surgical site and cause discomfort.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering the medication, the nurse should check to see that which of the following tests have been completed?

Correct Answer is B

Explanation

A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

A nurse is conducting a primary survey of a client who has sustained life threatening injuries due to a motor vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

A nurse is caring for a client who has named a person to serve as his health care proxy. The client talks about this type of advance directives. Which of the following statements by the client indicates a need for clarification?