A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

Assess for signs of infection.

Assess for a patent airway.

Assess ability to clear oral secretions.

Assess for ability to communicate.

Answer and Explanation

The Correct Answer is B

Choice A reason:

While assessing for signs of infection is important, ensuring a patent airway takes precedence immediately following surgery.

Choice B reason:

This statement is correct. Assessing for a patent airway is the top priority in postoperative care to ensure the patient can breathe effectively.

Choice C reason:

Assessing the ability to clear oral secretions is important, but it is secondary to ensuring a patent airway.

Choice D reason:

Assessing the ability to communicate is important, but it is not the immediate priority after surgical resection for oropharyngeal cancer.

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Correct Answer is B

Explanation

Choice A reason:

While thirst can be a sign of dehydration, it is not specific to recurrence of a GI bleed.

Choice B reason:

This is the correct answer. Tachycardia (rapid heart rate), hypotension (low blood pressure), and tachypnea (rapid breathing) are signs of potential recurrence of a GI bleed and should be closely monitored.

Choice C reason:

Diaphoresis (excessive sweating) and sudden onset of abdominal pain could be indicative of various conditions, but they are not specific to recurrence of a GI bleed.

Choice D reason:

Tarry, foul-smelling stools are indicative of melena, which is a sign of a GI bleed. However, in this scenario, the bleeding has been controlled, so this is not an expected sign of recurrence.

A. Shiny, moist stoma B. Rosebud-like stoma orifice C. Purplish-colored stoma D. Stoma oozing red drainage

Correct Answer is C

Explanation

Choice A reason:

A shiny, moist stoma is generally a healthy sign, indicating good blood supply and adequate hydration of the stoma tissue. It is not a cause for concern.

Choice B reason:

A rosebud-like stoma orifice is a normal appearance for some types of stomas. It indicates a healthy stoma with good blood supply. This finding is expected and does not warrant concern.

Choice C reason:

A purplish-colored stoma may indicate compromised blood supply to the stoma, which is a serious concern and should be reported to the provider promptly. It may suggest inadequate blood flow to the stoma, which could lead to tissue necrosis.

Choice D reason:

Stoma oozing red drainage may be normal immediately postoperatively. It can be due to some oozing from the surgical site, and if it's minimal and stops after a short while, it's generally not a cause for concern.

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A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is C

Explanation

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