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 ["C","D","E"]

Explanation

A. Increase hematocrit: Fluid overload typically leads to hemodilution, resulting in a decrease in hematocrit rather than an increase. Therefore, an increase in hematocrit would not be expected in a client with fluid overload.
B. Increased temperature: Fluid overload is not typically associated with an increased body temperature. Instead, fever may indicate an infection or another underlying cause. Therefore, an increased temperature would not be a typical finding in a client with fluid overload.
C. Increased heart rate: Fluid overload can lead to an increased heart rate as the body attempts to maintain adequate cardiac output in the presence of excess fluid volume. An elevated heart rate is a compensatory mechanism to maintain tissue perfusion despite the increased workload on the heart.
D. Increased respiratory rate: Fluid overload can cause pulmonary congestion, leading to increased respiratory effort and a higher respiratory rate as the body attempts to compensate for decreased gas exchange efficiency. An increased respiratory rate helps to improve oxygenation and remove excess carbon dioxide from the body.
E. Increased blood pressure: Fluid overload often leads to increased blood pressure due to the increased volume of circulating blood, which can strain the cardiovascular system. Elevated blood pressure is a common manifestation of fluid overload and reflects the increased workload on the heart and blood vessels.

A. Hypocalcemia B. Diuretic use C. Family history D. BMI less than 25

Correct Answer is C

Explanation

A. Hypocalcemia: Hypocalcemia, or low levels of calcium in the blood, is not typically associated with an increased risk of urolithiasis. In fact, hypercalcemia, or high levels of calcium, is more commonly linked to the formation of calcium-based kidney stones.
B. Diuretic use: Diuretic medications can increase urine production and may contribute to dehydration, which can predispose individuals to the formation of kidney stones. However, diuretic use alone is not as significant a risk factor as other factors like dehydration or specific dietary habits.
C. Family history: Family history of urolithiasis is a significant risk factor for developing kidney stones. Genetic factors can influence the likelihood of stone formation, and individuals with a family history of kidney stones are at a higher risk of experiencing them themselves.
D. BMI less than 25: Obesity and higher BMI (body mass index) are associated with an increased risk of urolithiasis. Excess body weight can lead to metabolic changes that promote the formation of kidney stones. Therefore, having a BMI less than 25 is less likely to be a risk factor compared to having a higher BMI.

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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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A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is C

Explanation

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