A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?

Relieve the client's pain.

Promote oral hygiene

Ensure adequate nutrition

Prevent aspiration

Answer and Explanation

The Correct Answer is D

A. Relieve the client's pain: While pain management is important for client comfort and recovery, it is not the priority immediately following intermaxillary fixation. Pain relief can be addressed once the more urgent concerns, such as preventing aspiration, are addressed.
B. Promote oral hygiene: Promoting oral hygiene is essential for preventing complications such as infection, but it is not the priority immediately after surgery and intermaxillary fixation. The client's airway and respiratory status should be the primary focus at this time.
C. Ensure adequate nutrition: Ensuring adequate nutrition is important for the client's overall recovery, but it is not the immediate priority after surgery and intermaxillary fixation. The priority is to prevent complications such as aspiration and maintain the client's airway.
D. Prevent aspiration: This is the priority action for the nurse. Intermaxillary fixation restricts the client's ability to open their mouth, increasing the risk of aspiration if vomiting occurs. The nurse should ensure that the client's airway is clear and that measures are in place to prevent aspiration, such as positioning the client appropriately and monitoring for signs of respiratory distress.

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Correct Answer is B

Explanation

A. "I will tell your family of your concern so that they can be here." This option involves the family in the client's care, which is important during end-of-life situations. However, it assumes that the client's primary concern is about the family's presence rather than exploring the underlying emotions or fears the client may be experiencing. While involving the family is beneficial, it may not directly address the client's emotional needs.
B. "I wonder if you are fearful of dying alone." This response demonstrates therapeutic communication by acknowledging the client's statement and exploring the underlying feelings or concerns behind it. It shows empathy and provides an opportunity for the client to express their emotions. Fear of dying alone is a common concern for many individuals facing the end of life, and addressing this fear can help alleviate distress.
C. "We will call your family in time for them to get here." While involving the family is important, this response primarily focuses on the logistics of family arrival rather than addressing the client's emotional needs. It may not fully explore or validate the client's feelings about dying alone.
D. "I will make sure a staff member is in your room at all times." While providing support and ensuring the client's comfort is essential, this response does not directly address the client's emotional needs or explore their concerns about dying alone. It also may not be feasible to have a staff member constantly present in the room. This option may not fully address the client's underlying fears or emotions related to dying alone.

A. The client runs 4 miles outdoors every afternoon B. The client eats 2 to 3 g of sodium containing foods C. The client eats foods high in tyramine D. The client drinks 2 litres of liquids daily

Correct Answer is A

Explanation

A. The client runs 4 miles outdoors every afternoon: Exercise, especially in hot weather, can lead to dehydration and increased sweating, which can result in decreased lithium excretion and increased lithium levels in the blood, leading to toxicity. Therefore, this factor puts the client at risk for lithium toxicity.
B. The client eats 2 to 3 g of sodium-containing foods: Sodium intake can affect lithium levels, as high sodium levels can increase lithium excretion and lower lithium levels. Therefore, eating sodium-containing foods is less likely to contribute to lithium toxicity.
C. The client eats foods high in tyramine: Tyramine-rich foods can interact with certain medications, such as MAOIs, but they do not directly increase the risk of lithium toxicity.
D. The client drinks 2 liters of liquids daily: Adequate hydration is important for clients taking lithium, as dehydration can increase lithium levels. Therefore, drinking 2 liters of liquids daily is not a risk factor for lithium toxicity.

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A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?

Nursing Test Bank

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