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","B","C","E","F"]
Explanation
A. Disorientation:
This may indicate a neurological or cognitive issue and requires further assessment.
B. Barrel-shaped chest:
This is a characteristic finding in COPD, but any change or worsening may need evaluation.
C. Yellow sputum:
Yellow or greenish sputum may indicate an infection, and follow-up is needed.
D. Nebulizer use:
Nebulizer use is part of the prescribed treatment.
E. Ankle edema:
Edema can be a sign of heart failure or other cardiovascular issues and should be investigated.
F. SaO2 92%:
Oxygen saturation of 92% is below the normal range. It may indicate respiratory compromise and needs attention.
G. Clubbing of fingers:
While clubbing can be associated with chronic respiratory conditions, it is not an immediate concern.
H. Lives alone:
Living alone may impact the client's support system but does not require immediate medical attention.
Correct Answer is D
Explanation
A. Wearing loose, non-constricting stockings: This instruction is not recommended for a client with DVT. Compression stockings, which are snug-fitting, may be prescribed to prevent DVT, but loose stockings would not provide the necessary compression.
B. Applying cool compresses to her legs: Cool compresses are not typically recommended for DVT. Warm compresses may be used to improve blood circulation, but cold compresses may not be suitable.
C. Taking an NSAID tablet daily: Nonsteroidal anti-inflammatory drugs (NSAIDs) are not typically recommended for individuals with DVT, especially when on anticoagulant therapy, as they may increase the risk of bleeding.
D. Flexing her knees and feet frequently: This is the correct answer. Encouraging the client to flex her knees and feet frequently helps promote blood circulation and reduces the risk of venous stasis, which can contribute to the formation of blood clots. It is a beneficial measure for clients with DVT.
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