A 79-year-old patient reports a pain level of 3 out of 10 and states, “Don’t worry, this is just part of getting old.” What is the best response?

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.

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.