A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?
Activity intolerance.
Fluid volume excess.
Ineffective airway clearance.
Altered nutrition; less than body requirements.
The Correct Answer is C
Choice A reason: Activity intolerance is important but not the highest priority immediately after surgery.
Choice B reason: Fluid volume excess can be a concern but is not as critical as ensuring effective airway clearance.
Choice C reason: Ineffective airway clearance is the highest priority as it directly impacts the client’s ability to breathe and maintain adequate oxygenation, which is crucial for postoperative recovery.
Choice D reason: Altered nutrition is also important but is not the immediate priority compared to airway clearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Mixing the next dose with food is not recommended because digoxin is better absorbed on an empty stomach and food may interfere with its absorption. Additionally, this option does not address the immediate issue of the infant vomiting after the dose.
Choice B reason: Administering a half dose is not appropriate because it may lead to incorrect dosing and potential under-treatment or toxicity. The exact dose must be given according to medical guidelines.
Choice C reason: Withholding the dose is the best course of action. If an infant vomits after receiving a dose of medication, particularly a critical one like digoxin, it is essential to wait until the next scheduled dose to avoid potential overdose or toxic effects.
Choice D reason: Giving another dose is not recommended because it could lead to toxicity, especially considering the infant might have partially absorbed the initial dose before vomiting.
Correct Answer is A
Explanation
Choice A reason: The catheter tubing is the most likely reservoir for the infection as it can harbor bacteria and introduce them into the urinary tract when not managed properly.
Choice B reason: The client's bed is an unlikely reservoir for the infection as it does not have direct contact with the urinary system.
Choice C reason: The urinary meatus is part of the normal flora but is not the primary reservoir for the infection in this scenario.
Choice D reason: The client's bladder is the site of the infection, not the reservoir that introduced the bacteria.
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