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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?

A.

Relieve the client's pain.

B.

Promote oral hygiene

C.

Ensure adequate nutrition

D.

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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Related Questions

Correct Answer is A

Explanation

A. CD4 T cell count 180 cells/mm3: In a client with HIV, monitoring the CD4 T cell count is crucial for assessing immune function and determining the progression of the disease. A CD4 T cell count of less than 200 cells/mm3 indicates severe immunosuppression and an increased risk of opportunistic infections, making it the priority laboratory value to monitor in this client.
B. Platelets 150,000/mm3: While platelet count is important for assessing clotting function, it is not the priority laboratory value in a client with HIV. Thrombocytopenia can occur in HIV but is often secondary to other factors such as medication side effects or opportunistic infections. However, a platelet count within the normal range of 150,000/mm3 is reassuring and does not require immediate intervention.
C. WBC 5000 mm3: White blood cell (WBC) count is essential for assessing overall immune function, but it is not the priority laboratory value in a client with HIV. A WBC count of 5000 mm3 is within the normal range and does not require urgent attention.
D. Positive Western blot test: While a positive Western blot test confirms HIV infection, it does not provide information about the client's current immune status or the need for immediate intervention. Confirmatory tests such as Western blot are important for diagnosis, but they do not provide ongoing monitoring of disease progression or immune function.

Correct Answer is ["5.6"]

Explanation

Let's calculate the amount of amoxicillin suspension the nurse should administer.

Steps:

  1. Convert toddler's weight to kilograms (kg):
    • Weight (kg) = Weight (lb) / 2.2 lb/kg
    • Weight (kg) = 33 lb / 2.2 lb/kg
    • Weight (kg) ≈ 15 kg
  2. Calculate total daily dose of amoxicillin:
    • Total dose (mg/day) = Dose per kg/day x Weight (kg)
    • Total dose (mg/day) = 30 mg/kg/day x 15 kg
    • Total dose (mg/day) = 450 mg/day
  3. Calculate amoxicillin needed per dose (since it's given every 12 hours, we need half the daily dose):
    • Dose per administration (mg) = Total daily dose (mg/day) / Number of doses/day
    • Dose per administration (mg) = 450 mg/day / 2 doses/day
    • Dose per administration (mg) = 225 mg
  4. Calculate the volume (mL) of suspension based on the concentration:
    • Concentration (mg/mL) = Amount of amoxicillin (mg) / Volume (mL)
    • We need to rearrange the formula to find the volume (mL): Volume (mL) = Amount of amoxicillin (mg) / Concentration (mg/mL)
    • Known values:
      • Amount of amoxicillin (mg) = 225 mg (calculated in step 3)
      • Concentration (mg/mL) = 200 mg/5 mL (from available suspension)
    • Volume (mL) = 225 mg / (200 mg/5 mL)
    • To simplify the calculation, divide both numerator and denominator by 25: Volume (mL) = (225 mg / 25) / (200 mg/5 mL / 25) Volume (mL) = 9 mL / 4 mL/mL. Pay attention here, dividing by mL/mL is the same as multiplying by 1)
    • Volume (mL) = 9 mL
  5. Round the answer to the nearest tenth:
    • Volume (mL) ≈ 5.6 mL

Therefore, the nurse should administer approximately 5.6 mL of amoxicillin suspension per dose.

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