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.
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Related Questions
Correct Answer is D
Explanation
A. Dependent edema: Dependent edema is more commonly associated with right-sided heart failure. In left-sided heart failure, fluid accumulates in the lungs, leading to pulmonary symptoms such as cough and frothy sputum.
B. Jugular distention: Jugular distention is often associated with right-sided heart failure due to impaired blood flow from the right atrium into the right ventricle. It is less likely to be prominent in left-sided heart failure.
C. Nocturnal polyuria: Nocturnal polyuria (increased urination at night) is a common symptom of heart failure, but it is not specific to left-sided heart failure. It can be seen in both left- and right-sided heart failure.
D. Frothy sputum: This is the correct answer. Left-sided heart failure can lead to pulmonary congestion, resulting in the accumulation of fluid in the lungs. Frothy, pink-tinged sputum is a characteristic finding in left-sided heart failure and is often associated with pulmonary edema.
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.
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