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 D
Explanation
A. Instruct the client to stay in the same position for 2 min: While it is important for the client to remain in a supine position with the head tilted back slightly after instilling nasal decongestant drops, there is no need for the client to remain in the same position for a specific duration such as 2 minutes.
B. Tell the client to blow her nose gently before the instillation: Blowing the nose before instilling nasal decongestant drops is not necessary and may cause irritation to the nasal passages. The drops should be instilled directly into the nasal passages without prior blowing of the nose.
C. Assist the client to a side-lying position: There is no need to assist the client to a side-lying position for the administration of nasal decongestant drops. The drops are typically administered with the client in a seated or supine position with the head tilted back slightly.
D. Hold the dropper 2 cm (1 in) above the nares: This is the correct action. Holding the dropper approximately 2 cm (1 in) above the nares allows for precise instillation of the drops into the nasal passages without touching the dropper to the nares, which helps prevent contamination.
Correct Answer is D
Explanation
A. Take the medication with meals: Beclomethasone is an inhaled corticosteroid used to prevent asthma symptoms. It should be taken as prescribed by the healthcare provider, usually inhaled at specific times each day. Taking the medication with meals is not necessary, as it does not affect its efficacy or absorption.
B. Check the pulse after medication administration: Checking the pulse is not typically indicated after administering inhaled beclomethasone. Beclomethasone is a corticosteroid inhaler used for long-term control of asthma symptoms and is not associated with significant cardiovascular effects that would necessitate pulse monitoring.
C. Limit caffeine intake: Limiting caffeine intake is not specifically related to the administration of inhaled beclomethasone. However, caffeine can exacerbate some asthma symptoms in susceptible individuals, so general advice to limit caffeine intake may be beneficial for managing asthma symptoms overall. Still, it's not directly related to the administration of this medication.
D. Rinse the mouth after administration: This is the correct action. Inhaled corticosteroids like beclomethasone can cause local side effects such as oral candidiasis (thrush) or dysphonia (hoarseness) due to deposition of the medication in the mouth and throat. Rinsing the mouth with water after each dose helps minimize these side effects by reducing the amount of medication left in the mouth, thereby decreasing the risk of oral candidiasis and other local adverse effects.
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