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 B

Explanation

a. Low BP and low pulse rate: In hypovolemic shock, there is a decrease in blood volume,

leading to low blood pressure. However, the body compensates by increasing the heart rate to maintain perfusion to vital organs.

b. Low BP and high pulse rate: This is indicative of hypovolemic shock. The low blood pressure results from decreased blood volume, while the high pulse rate is a compensatory mechanism to maintain cardiac output.

c. High BP and low pulse rate: This combination is not typical of hypovolemic shock. High blood pressure is not expected in the presence of decreased blood volume.

d. High BP and high pulse rate: While a high pulse rate is expected in hypovolemic shock, high blood pressure is not a characteristic finding.

A. Instruct the client to place his chin to his chest and swallow. B. Withdraw the tube if the client gags during insertion. C. Place the client in a supine position. D. Measure the tube for insertion from the tip of the nose to the umbilicus.

Correct Answer is A

Explanation

a. Instruct the client to place his chin to his chest and swallow: This technique helps facilitate the passage of the nasogastric tube through the pharynx and into the esophagus.

b. Withdraw the tube if the client gags during insertion: Gagging is a normal response, and

withdrawing the tube may lead to repeated attempts and discomfort for the client. Encouraging the client to swallow can help overcome the gag reflex.

c. Place the client in a supine position: The client is usually positioned in a semi-Fowler's position or upright to ease tube insertion and minimize the risk of aspiration.

d. Measure the tube for insertion from the tip of the nose to the umbilicus: The proper

measurement for nasogastric tube insertion is typically from the tip of the nose to the earlobe and then down to the xiphoid process, not the umbilicus.

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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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