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 C
Explanation
A. Asking the client if they have talked to their parents about their anxiety may not be appropriate, as it assumes the client is comfortable discussing their concerns with their parents. It's important to establish rapport and trust with the client before delving into personal matters such as family dynamics.
B. Asking "Why do you think you are so anxious?" may come across as confrontational and put the client on the defensive. It's important to approach the client's concerns with empathy and understanding rather than seeking an explanation for their anxiety.
C. This response acknowledges the client's feelings and validates their experience, showing empathy and understanding. It opens the door for further exploration of the client's concerns and allows the nurse to provide support and assistance.
D. While assessing the duration of symptoms is important, asking "How long has this been going on?" as an initial response may feel dismissive to the client's current distress. Starting with an empathetic acknowledgment of the client's experience can help build rapport and trust before delving into more specific questions about the duration and severity of symptoms.
Correct Answer is B
Explanation
A. While heparin and warfarin both work as anticoagulants, IV heparin is not typically used to increase the effects of warfarin or decrease the length of hospital stay. Heparin is often administered initially to rapidly achieve therapeutic anticoagulation while waiting for warfarin to reach its full therapeutic effect, but it is not intended to directly enhance the action of warfarin.
B. This statement is accurate and provides a clear explanation to the client. Warfarin, an oral anticoagulant, takes several days to achieve a therapeutic level in the bloodstream and to exert its anticoagulant effect. During this time, IV heparin is continued to prevent clot formation until the therapeutic level of warfarin is reached.
C. While both heparin and warfarin work to prevent blood clots, they do not directly dissolve existing clots. Rather, they prevent the formation of new clots and the growth of existing ones. This explanation does not fully address the client's question regarding why both medications are necessary.
D. Discontinuing IV heparin prematurely without reaching a therapeutic level of warfarin could increase the risk of thrombus formation or embolization. Therefore, discontinuing IV heparin should be done under the guidance of the provider based on the client's INR levels and the target therapeutic range for warfarin.
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