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. "It requires lying quietly on one side": This is the correct answer. During an echocardiogram, the client is typically asked to lie on their left side to obtain clear images of the heart. The test is non-invasive and involves using ultrasound waves to create images of the heart's structures.
B. "It might cause slight discomfort in the chest area": Echocardiograms are generally painless and do not cause discomfort. They are a non-invasive imaging technique that uses sound waves.
C. "It is best to have no food or beverages the day of the test": While the client may be instructed to avoid eating or drinking shortly before the test, this statement is too restrictive. The specific fasting instructions will be provided by the healthcare provider or facility.
D. "It takes about 5 or 10 minutes": The duration of an echocardiogram can vary, but it typically takes longer than 5 or 10 minutes. The test duration depends on various factors, including the complexity of the study and the information needed.
Correct Answer is D
Explanation
A. A friction rub:A friction rub is a sound caused by the rubbing of inflamed pericardial layers and is not classified as a heart sound like S1 or S2. It is unrelated to the sequence of heart sounds.
B. A split second heart sound S₂:A split S₂ occurs during the closure of the aortic and pulmonary valves and is heard after S1, not before.
C. The third heart sound (S3):S3, or the ventricular gallop, occurs shortly after S2 during early diastole and indicates rapid ventricular filling. It is not heard before S1.
D. The fourth heart sound (S4):S4, known as the "atrial gallop," occurs just before S1 during atrial contraction. It is associated with a stiff or hypertrophied ventricle and is often indicative of underlying heart disease, especially in older adults.
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