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

Answer and Explanation

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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Correct Answer is D

Explanation

a. Eating dinner early in the evening: Eating dinner early can actually be a positive factor in preventing heartburn by allowing more time for digestion before lying down.

b. Sleeping on a large wedge-style pillow: Elevating the upper body can help prevent acid reflux, so sleeping on a wedge-style pillow may be a helpful strategy.

c. Consuming low-fat meats: Low-fat meats are less likely to contribute to heartburn compared to high-fat meats.

d. Drinking orange juice regularly: Orange juice is acidic and can contribute to heartburn,

especially if consumed regularly. The acid content can irritate the esophagus and worsen GERD symptoms.

A. “Managing my cholesterol will reduce my chances of having a stroke.” B. “My blood pressure needs to stay a little elevated for good blood flow to my brain.” C. “Using oral contraceptives provides me with protection from a stroke.” D. “I can safely have up to 3 alcoholic drinks a day.”

Correct Answer is A

Explanation

a. “Managing my cholesterol will reduce my chances of having a stroke.”: High cholesterol is a risk factor for stroke, and managing it can help reduce the risk.

b. “My blood pressure needs to stay a little elevated for good blood flow to my brain.”:

Maintaining normal blood pressure is essential for preventing stroke, and elevated blood pressure is a risk factor for stroke.

c. “Using oral contraceptives provides me with protection from a stroke.”: Oral contraceptives, especially in the presence of other risk factors, can increase the risk of stroke.

d. “I can safely have up to 3 alcoholic drinks a day.”: Excessive alcohol consumption is a risk factor for stroke, and moderation is advised to reduce the risk.

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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?

Nursing Test Bank

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