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. "I will be sure to take the albuterol before taking the cromolyn": Taking albuterol before cromolyn is the correct sequence because albuterol is a bronchodilator that helps open the airways quickly, while cromolyn is a mast cell stabilizer that helps prevent asthma symptoms. Taking albuterol first allows for better penetration of cromolyn into the airways. Therefore, this statement indicates an understanding of the appropriate sequence for using the medications.
B. "I will use both medications immediately after exercising": While it is essential to use albuterol before exercise to prevent exercise-induced bronchospasm, using cromolyn immediately after exercise is not typically indicated. Cromolyn is more effective when used prophylactically to prevent asthma attacks triggered by allergens or exercise rather than as an acute rescue medication.
C. "If my breathing begins to feel tight, I will use the cromolyn immediately": Cromolyn is not indicated for the immediate relief of acute bronchospasm. It works best when used regularly to prevent asthma symptoms rather than as a rescue medication during an asthma attack. Albuterol is the appropriate choice for immediate relief of tightness or wheezing.
D. "I will administer the medications 10 minutes apart": While it's important to space out the administration of different medications to ensure proper absorption and effectiveness, the specific timing between albuterol and cromolyn may vary based on individual instructions from the healthcare provider. Generally, it's recommended to take albuterol first, followed by cromolyn after a brief interval.

A. The client runs 4 miles outdoors every afternoon B. The client eats 2 to 3 g of sodium containing foods C. The client eats foods high in tyramine D. The client drinks 2 litres of liquids daily

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.

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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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Explanation

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