A nurse is caring for a patient after a radical neck dissection.
What should be the nurse’s priority in the immediate postoperative period?
Ineffective airway clearance related to thick, copious secretions.
Impaired verbal communication related to the tracheostomy.
High risk for infection related to surgical incisions.
Malnourishment related to NPO Status and dysphagia.
The Correct Answer is A
Rationale for Choice A:
Ineffective airway clearance is the most immediate and life-threatening concern in the postoperative period following a radical neck dissection. This procedure involves extensive removal of lymph nodes and tissues in the neck, which can significantly disrupt normal respiratory function and airway patency. Here's a detailed explanation of the factors contributing to this risk:
Altered Respiratory Anatomy: The surgical resection of tissues and lymph nodes can directly impact the structure and function of the airway. This includes potential narrowing of the trachea, vocal cord dysfunction, and impaired laryngeal movement, all of which can hinder effective airflow.
Thick, Copious Secretions: The surgical trauma and manipulation of tissues often lead to increased production of thick, tenacious secretions in the respiratory tract. These secretions can obstruct the airway, making it difficult for the patient to clear them effectively.
Impaired Cough Reflex: The surgical dissection may disrupt the nerves involved in the cough reflex, which is a crucial mechanism for clearing secretions from the airway. This further impedes the patient's ability to maintain a patent airway.
Risk of Aspiration: Accumulation of secretions in the airway elevates the risk of aspiration, which can lead to pneumonia and other serious complications.
Potential for Edema: Postoperative swelling in the neck tissues can further compress the airway, exacerbating the risk of obstruction.
Nursing Interventions for Ineffective Airway Clearance:
Prompt recognition and management of ineffective airway clearance are essential to prevent respiratory compromise and ensure patient safety. Here are key nursing interventions that should be prioritized:
Frequent Assessment: Continuously monitor respiratory rate, effort, breath sounds, oxygen saturation, and level of consciousness for any signs of respiratory distress.
Positioning: Elevate the head of the bed to 30-45 degrees to promote lung expansion and facilitate drainage of secretions. Suctioning: Regularly suction the airway to remove secretions, using aseptic technique and proper suctioning pressure.
Deep Breathing and Coughing Exercises: Encourage and assist the patient with deep breathing and coughing exercises to mobilize secretions.
Humidification: Provide humidified oxygen or use a nebulizer to help thin secretions and make them easier to expectorate.
Chest Physiotherapy: Perform chest physiotherapy techniques, such as percussion and vibration, to loosen secretions and promote their removal.
Monitoring Fluid Balance: Maintain adequate hydration to help thin secretions, while closely monitoring fluid intake and output to prevent fluid overload.
Addressing Other Choices:
While the other choices may also be relevant concerns in the postoperative period, they do not pose the same immediate threat to life as ineffective airway clearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A: Refer questions to the nursing supervisor.
Choice A rationale: By referring inquiries from other nurses to the nursing supervisor, the nurse maintains patient privacy and upholds healthcare privacy regulations, such as the Health Insurance Portability and Accountability Act (HIPAA). These regulations mandate that patient information should only be disclosed on a need-to-know basis. Referring questions to the nursing supervisor ensures that any information released is managed through the appropriate channels and protects the patient's confidentiality.
Choice B rationale: Transferring calls directly to the patient's room could infringe on their privacy and disrupt their care or rest. It is not the nurse's role to decide if the patient should be disturbed, and doing so may potentially compromise patient care and satisfaction.
Choice C rationale: Acknowledging that the person is a patient on the unit can violate confidentiality rules, as it confirms the individual's presence in the hospital and could lead to speculation about their condition. Nurses must maintain patient privacy by refraining from sharing any information, even if it seems harmless.
Choice D rationale: Contacting the patient's provider does not directly address the issue of handling inquiries from other nurses and could breach confidentiality if the provider discloses information without the patient's consent. Additionally, the provider may not be immediately available, which would delay addressing the inquiries and potentially expose the patient's privacy further.
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale:
Intravenous theophylline (aminophylline) is a bronchodilator that can be life-saving in cases of anaphylactic shock with bronchospasm. It works by relaxing the smooth muscles in the airways, allowing for increased airflow.
Anaphylactic shock can cause severe bronchospasm, which can lead to respiratory failure and death. Theophylline can help to reverse bronchospasm and improve oxygenation.
The dosage of theophylline should be individualized based on the patient's weight and severity of bronchospasm. It is important to monitor the patient's heart rate and blood pressure while administering theophylline, as it can cause tachycardia and arrhythmias.
Choice B rationale:
Culturing the site of the bee sting and administering antibiotics is not appropriate in the acute management of anaphylactic shock. Anaphylaxis is an allergic reaction, not an infection. Antibiotics will not address the underlying cause of the reaction.
Antibiotics may be necessary if the patient develops a secondary infection at the site of the bee sting. However, this is not a priority in the acute setting.
Choice C rationale:
Providing sips of water to moisten the mouth and throat is not a priority in the acute management of anaphylactic shock. The patient's primary concern is likely to be difficulty breathing.
If the patient is able to drink, it is important to ensure that they are able to do so safely without compromising their airway. However, this is not a life-saving intervention.
Choice D rationale:
Diphenhydramine (Benadryl) is an antihistamine that can help to block the effects of histamine, one of the chemicals released during an allergic reaction. This can help to reduce symptoms such as swelling, itching, and hives.
Diphenhydramine can also help to prevent further release of histamine, which can help to stop the progression of the allergic reaction.
Diphenhydramine is available over-the-counter, but it is important to consult a healthcare professional before administering it to a patient in anaphylactic shock.
Choice E rationale:
Surgical management of the airway may be necessary if the patient's airway becomes compromised due to swelling. This could include intubation or a tracheostomy.
It is important to be prepared for surgical airway management in case it is needed. Early preparation can help to prevent delays in treatment and improve the patient's chances of survival.
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