A nurse is caring for a client after a radical neck dissection.
To which of the following should the nurse give 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
Choice A rationale
Ineffective airway clearance is the immediate priority due to the anatomical changes from the radical neck dissection and the presence of a tracheostomy. Surgical manipulation and edema can obstruct the airway. Thick, copious secretions from the respiratory tract require constant monitoring and suctioning to prevent mucous plugs and subsequent respiratory distress or arrest, making Airway, Breathing, Circulation (ABC) the paramount concern in the immediate postoperative period.
Choice B rationale
Impaired verbal communication is a valid concern following a tracheostomy as the client cannot phonate normally. However, this is a psychosocial and comfort need, which is secondary to maintaining a patent and clear airway. The inability to speak, while distressing, does not pose an immediate threat to the client's survival or physiological stability in the way that an obstructed airway does.
Choice C rationale
High risk for infection is a significant concern following any major surgery, especially a radical neck dissection with extensive tissue exposure and incision lines. Proper aseptic technique and meticulous wound care are essential. Despite this, airway management is governed by the ABC principle; a patient cannot recover from an infection if they cannot breathe adequately.
Choice D rationale
Malnourishment is a valid long-term concern for a client who is NPO and may have subsequent dysphagia (difficulty swallowing). However, meeting nutritional needs is a lower-priority need in the immediate postoperative phase compared to ensuring adequate tissue oxygenation through a clear and patent airway. Nutritional support will become a focus once the client is medically stable and the immediate surgical risks have passed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Offering the client apple juice is an action to advance the diet, but it is not the initial priority after surgery. Postoperative clients must first demonstrate adequate gastrointestinal motility before introducing any fluids or food to prevent complications like vomiting, aspiration, or abdominal distention due to paralytic ileus, which is common following anesthesia and abdominal manipulation.
Choice B rationale
Elevating the client's head of bed is a crucial safety measure to prevent aspiration when administering food or fluids. However, the first action must be to assess the return of peristalsis because, without bowel sounds, administering clear liquids poses a risk that outweighs positional safety, necessitating the abdominal assessment initially.
Choice C rationale
Ordering a lunch tray represents an advancement to a solid diet, which is inappropriate and contraindicated until the client tolerates clear liquids and has a return of bowel function as evidenced by active peristaltic sounds and passing flatus. Introducing solids prematurely significantly increases the risk of ileus complications.
Choice D rationale
Auscultating the client's abdomen to verify the presence of active bowel sounds is the priority assessment before introducing any oral intake in a postoperative client. The return of peristalsis indicates that the digestive tract has recovered sufficiently from the effects of anesthesia and surgery to safely process fluids, minimizing the risk of ileus and aspiration.
Correct Answer is ["50"]
Explanation
Step 1 is to calculate the total time for the infusion in minutes:. 8 hr × 60 min/hr = 480 min.
Step 2 is to calculate the gtt/min using the formula Volume in mL÷Time in min/Drop factor. (400 mL ÷ 480 min) × 60 gtt/mL.
Step 3 is to calculate the intermediate value of the mL/min:. 400 mL ÷ 480 min = 0.8333 mL/min.
Step 4 is to calculate the gtt/min:. 0.8333 mL/min × 60 gtt/mL = 49.998 gtt/min.
Step 5 is to round the answer to the nearest whole number:. 49.998 gtt/min rounds to 50 gtt/min. The final calculated answer is 50 gtt/min.
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