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. Restrict the client's fluid intake: There is typically no need to restrict fluid intake after a cardiac catheterization. Adequate hydration is important for preventing complications and promoting recovery.
B. Ambulate the client 1 hr following the procedure: While early ambulation is encouraged in many cases, the timing may vary based on the specific protocols of the healthcare provider. It is important to follow the healthcare provider's orders regarding post-catheterization ambulation.
C. Instruct the client to perform range-of-motion exercises to his lower extremities: Range-of-motion exercises are beneficial to prevent complications such as venous stasis and deep vein thrombosis. However, the specific exercises and timing may vary. It is important to follow the healthcare provider's instructions.
D. Perform neurovascular checks with vital signs: This is the correct answer. After a cardiac catheterization accessed through the femoral artery, it is crucial to monitor neurovascular status in the affected extremity. Assessing peripheral pulses, skin color, temperature, and capillary refill, along with monitoring vital signs, helps detect any signs of complications such as bleeding or vascular compromise.
Correct Answer is ["A","C","D"]
Explanation
A. Apply pressure to the nares:
Applying gentle pressure to the nares can help control bleeding.
B. Tilt the client's head backward:
Tilt the head forward slightly to prevent blood from flowing down the back of the throat and to avoid swallowing blood.
C. Place ice to the bridge of the client's nose:
Cold packs can help constrict blood vessels and reduce bleeding.
D. Move the client into high-Fowler's position:
Sitting the client upright in a high-Fowler's position can minimize blood flow to the head and reduce bleeding.
E. Instruct the client to blow his nose:
Blowing the nose may disrupt clots and increase bleeding.
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