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 B
Explanation
A. Foot ulcers: Foot ulcers are more commonly associated with the later stages of peripheral arterial disease (PAD) when there is significant impairment of blood flow to the extremities, leading to tissue damage and delayed wound healing.
B. Intermittent claudication: This is the correct answer. Intermittent claudication is a classic symptom of PAD in the early stage. It is characterized by cramping leg pain or discomfort that occurs during physical activity, such as walking, and is relieved by rest. It is caused by insufficient blood flow to meet the demands of the muscles during exercise.
C. Rest pain: Rest pain is typically a symptom of more advanced PAD. It occurs when blood flow is severely compromised even at rest, leading to pain in the affected extremity that is not relieved by activity.
D. Dependent rubor: Dependent rubor is a sign of severe PAD and occurs when the foot or leg becomes red or flushed when in a dependent position. It is associated with compromised arterial blood flow.
Correct Answer is B
Explanation
A. Myringotomy: Myringotomy is a procedure involving the insertion of tubes into the eardrum to treat conditions such as chronic ear infections. This procedure is not associated with a significant risk of deep-vein thrombosis.
B. Hip arthroplasty: Hip arthroplasty, or hip replacement surgery, is associated with an increased risk of deep-vein thrombosis due to factors such as immobility, surgical trauma, and alterations in blood flow. Prophylactic measures, such as anticoagulant medications and early ambulation, are often employed to reduce this risk.
C. Cataract extraction: Cataract extraction is a procedure to remove a cloudy lens from the eye. This surgery is not typically associated with a high risk of deep-vein thrombosis.
D. Laparoscopic appendectomy: Laparoscopic appendectomy, a minimally invasive procedure to remove the appendix, is generally associated with a lower risk of deep-vein thrombosis compared to major orthopedic surgeries like hip arthroplasty.
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