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.

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Correct Answer is A

Explanation

A. The client runs 4 miles outdoors every afternoon: Exercise, especially in hot weather, can lead to dehydration and increased sweating, which can result in decreased lithium excretion and increased lithium levels in the blood, leading to toxicity. Therefore, this factor puts the client at risk for lithium toxicity.
B. The client eats 2 to 3 g of sodium-containing foods: Sodium intake can affect lithium levels, as high sodium levels can increase lithium excretion and lower lithium levels. Therefore, eating sodium-containing foods is less likely to contribute to lithium toxicity.
C. The client eats foods high in tyramine: Tyramine-rich foods can interact with certain medications, such as MAOIs, but they do not directly increase the risk of lithium toxicity.
D. The client drinks 2 liters of liquids daily: Adequate hydration is important for clients taking lithium, as dehydration can increase lithium levels. Therefore, drinking 2 liters of liquids daily is not a risk factor for lithium toxicity.

A. Clear the respiratory tract B. Cut the umbilical cord C. Stimulate the infant to cry D. Dry the infant off and cover the head

Correct Answer is A

Explanation

A. Clear the respiratory tract: This is the correct action. Clearing the newborn's respiratory tract is the priority immediately after delivery to ensure adequate breathing. The nurse should suction the mouth and nose with a bulb syringe to remove any mucus or amniotic fluid and facilitate effective respiration.
B. Cut the umbilical cord: Cutting the umbilical cord is an important step in newborn care, but it is typically done after ensuring the newborn's immediate respiratory needs are met. The priority immediately after delivery is to establish effective breathing.
C. Stimulate the infant to cry: While stimulating the infant to cry can help clear the airways and establish effective breathing, it should be done concurrently with clearing the respiratory tract. Therefore, clearing the respiratory tract takes precedence over stimulating the infant to cry.
D. Dry the infant off and cover the head: Drying the infant and covering the head are important steps in newborn care to prevent heat loss and maintain thermal regulation. However, these actions can be done after ensuring the newborn's respiratory tract is clear and breathing is established.

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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

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