A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?
Tissue integrity
Pain severity
Airway patency
Wound drainage
The Correct Answer is C
A. Tissue integrity: While assessing tissue integrity is important, ensuring airway patency takes precedence in the immediate postoperative period, especially following a procedure involving the larynx. Maintaining a patent airway is a critical priority.
B. Pain severity: Pain assessment is important, but it is not the primary concern immediately postoperatively in the context of a partial laryngectomy. Airway patency is of higher priority.
C. Airway patency: This is the correct answer. Following a partial laryngectomy, there may be concerns related to airway compromise due to the surgical procedure. The nurse should assess the airway first to ensure there are no obstructions or complications affecting the client's ability to breathe.
D. Wound drainage: While assessing wound drainage is important for monitoring surgical sites, it is not the first priority in the immediate postoperative period following a partial laryngectomy. Airway patency is a more critical concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cellular hypoxia: Hemoglobin carries oxygen to the body's tissues. A low hemoglobin level, as well as a low hematocrit, indicates a reduced oxygen-carrying capacity of the blood, putting the client at risk for cellular hypoxia. Symptoms may include fatigue, weakness, and shortness of breath.
B. Prolonged bleeding: Hemoglobin and hematocrit levels are not directly indicative of a risk of prolonged bleeding. Prolonged bleeding is more related to platelet function and clotting factors.
C. Impaired immunity: Hemoglobin and hematocrit levels are not directly indicative of impaired immunity. Immune function is more closely associated with white blood cell count and function.
D. Fluid retention: Hemoglobin and hematocrit levels are not directly associated with fluid retention. Fluid retention is more related to factors such as sodium balance and kidney function.
Correct Answer is D
Explanation
A. Troponin is a lipid whose levels reflect the risk for coronary artery disease: This statement is incorrect. Troponin is not a lipid, and its levels do not reflect the risk for coronary artery disease. Troponin is a protein associated with muscle tissue.
B. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues: While troponin indicates damage to muscle tissues, it is specifically associated with cardiac muscle, not brain or skeletal muscle tissues.
C. Troponin is a protein that helps transport oxygen throughout the body: This statement is incorrect. While proteins in the blood may contribute to oxygen transport, troponin's primary role is in muscle contraction, particularly in the heart.
D. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart: This is the correct answer. Troponin is a protein found in cardiac muscle cells, and when there is damage to the heart, such as during a myocardial infarction, troponin is released into the bloodstream. Elevated troponin levels in the blood are indicative of myocardial injury or infarction.
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