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. Potassium level of 3.0 mEq/L: Hypokalemia is a potential adverse effect of digoxin, and a

potassium level of 3.0 mEq/L is below the normal range. Low potassium levels can increase the risk of digoxin toxicity.

b. Heart rate of 66/min: A heart rate of 66/min is within the normal range. Digoxin is used to

treat conditions like atrial fibrillation, and the heart rate should be within an appropriate range for the client's condition.

c. BP of 132/82 mm Hg: Blood pressure within the normal range does not require immediate reporting in the context of digoxin administration.

d. Digoxin level of 1.2 ng/ml: The digoxin level of 1.2 ng/ml is within the therapeutic range, and it does not require immediate reporting.

A. Prothrombin time (PT) B. Platelet count C. White blood cell count (WBC) D. Activated partial thromboplastin time (aPTT)

Correct Answer is A

Explanation

a. Prothrombin time (PT): Warfarin affects the extrinsic pathway of the coagulation cascade, and PT is the primary diagnostic test used to monitor the therapeutic effect of warfarin. It measures

the time it takes for blood to clot.

b. Platelet count: Platelet count assesses the number of platelets in the blood and is not specifically used to monitor the effect of warfarin.

c. White blood cell count (WBC): WBC count assesses the number of white blood cells and is not specifically used to monitor the effect of warfarin.

d. Activated partial thromboplastin time (aPTT): While aPTT is a valuable test for monitoring the therapeutic effect of heparin, it is not the primary test for warfarin. Warfarin primarily affects the extrinsic pathway, and PT is more appropriate for monitoring its effects.

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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

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Correct Answer is A

Explanation

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