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 C
Explanation
A. The pain persists with rest and organic nitrates: This statement is incorrect. Anginal pain typically improves with rest and can be relieved by the administration of organic nitrates.
B. The pain usually lasts longer than 20 min: This statement is incorrect. Anginal pain is often brief and lasts for a few minutes, typically less than 20 minutes.
C. Exertion and anxiety can trigger the pain: This is the correct answer. Anginal pain is often triggered by activities that increase the workload of the heart, such as exertion or emotional stress (anxiety). These triggers lead to an increased demand for oxygen by the heart muscle, which may exceed the compromised blood supply, resulting in angina.
D. The pain often radiates to the jaw or the back: This statement is correct. Anginal pain may radiate to the jaw, back, shoulder, arm, or neck. The radiation of pain is a characteristic feature of angina.
Correct Answer is B
Explanation
A. "The medication can take up to 15 minutes to take effect." - This statement is not accurate, sublingual nitroglycerin works rapidly and often provides relief within a few minutes.
B. Sublingual nitroglycerin is administered by placing the tablet under the tongue, and it should be allowed to dissolve or be absorbed directly into the bloodstream through the mucous membranes. It is not swallowed or chewed. The small sip of water can help facilitate the dissolving process.
C. "Avoid taking the medication prior to exercising." - This statement is not accurate. Nitroglycerin can be taken before anticipated exertion or activities that may trigger angina to prevent anginal episodes during physical activity.
D. "Stop taking the medication and notify your provider if you develop a headache." - While headaches are a common side effect of nitroglycerin, they are generally transient and not a reason to stop taking the medication. Persistent or severe headaches should be reported to the healthcare provider.
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