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
Malnourishment related to NPO status and dysphagia
High risk for infection related to surgical incisions
Impaired verbal communication related to the tracheostomy
The Correct Answer is A
a. Ineffective airway clearance: This is the priority as it addresses the immediate threat to the client's respiratory status. Accumulation of thick, copious secretions can lead to airway
obstruction and respiratory distress.
b. Malnourishment: While important, addressing malnourishment is not an immediate
postoperative priority. The client may receive nutrition through alternative means until normal swallowing function is restored.
c. High risk for infection: Infection is a concern, but ensuring airway clearance takes precedence in the immediate postoperative period.
d. Impaired verbal communication: Verbal communication is important, but it is not as immediate a concern as ensuring the airway is clear to prevent respiratory compromise.
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Related Questions
Correct Answer is D
Explanation
a. Encourage the client to take small bites: While encouraging small bites is important, the priority for a client with dysphagia is to ensure they are in an upright position to prevent aspiration.
b. Place food in the unaffected side of the mouth: Placing food in the unaffected side of the mouth may not prevent aspiration and does not address the priority of positioning.
c. Offer mouth care before meals: While oral hygiene is important, it is not the priority when addressing the risk of aspiration during feeding.
d. Place the client in the upright position: The upright position helps prevent aspiration during swallowing, which is crucial for clients with dysphagia.
Correct Answer is C
Explanation
a. Type A: Type A blood may not be compatible with the client's blood type, and it is not considered a universal donor.
b. Type B: Similar to Type A, Type B blood may not be compatible with the client's blood type, and it is not considered a universal donor.
c. Type O: Type O negative blood is considered the universal donor for packed red blood cells. It can be administered to individuals with any blood type in an emergency situation.
d. Type AB: While Type AB is considered the universal recipient for blood transfusions, it is not the universal donor.
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