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 A

Explanation

A. Decreased calcium level B. Decreased potassium level C. Elevated magnesium level D. Elevated sodium level

Correct Answer is B

Explanation

a. Decreased calcium level: NG tube drainage is more likely to result in hypokalemia (decreased potassium) than hypocalcemia (decreased calcium).

b. Decreased potassium level: NG tube drainage, which contains stomach contents, can lead to loss of potassium. Monitoring for hypokalemia is crucial as it can result in cardiac dysrhythmias.

c. Elevated magnesium level: NG tube drainage is not typically associated with an increase in magnesium levels.

d. Elevated sodium level: NG tube drainage may contribute to sodium loss, leading to hyponatremia, rather than hypernatremia.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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