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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "HIPAA is a federal law, not a state law": This statement is correct. HIPAA, the Health Insurance Portability and Accountability Act, is a federal law enacted in 1996 to protect the privacy and security of individually identifiable health information. It applies nationwide and sets national standards for the protection of health information.
B. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form": This statement is accurate. HIPAA regulations govern the privacy and security of protected health information (PHI) in various forms, including verbal, electronic, and written formats. The regulations apply to covered entities such as healthcare providers, health plans, and healthcare clearinghouses.
C. "Information about a client can be disclosed to family members at any time": This statement is incorrect. HIPAA regulations restrict the disclosure of protected health information (PHI) to third parties, including family members, without the patient's authorization, except in certain circumstances outlined in the law. While there are provisions for sharing PHI with family members involved in the patient's care, such disclosures typically require the patient's consent or may be permitted under specific exceptions, such as in emergency situations or when the patient is incapacitated.
D. "A client's address would be an example of personally identifiable information": This statement is accurate. Personally identifiable information (PII) under HIPAA includes any information that can be used to identify an individual, directly or indirectly, including names, addresses, dates of birth, social security numbers, and other demographic data. Therefore, a client's address would indeed be considered personally identifiable information under HIPAA.
Correct Answer is B
Explanation
A. "I will wear gloves when removing food from the freezer": This statement demonstrates understanding of the need to protect the hands from cold exposure, which can trigger Raynaud's disease symptoms. Wearing gloves when handling cold objects, such as food from the freezer, helps minimize the risk of a vasospastic episode.
B. "I will take my medications at the first sign of an attack": This statement indicates a misunderstanding of the appropriate use of medications for Raynaud's disease. While medications such as calcium channel blockers may be prescribed to prevent or reduce the frequency and severity of attacks, they are typically taken regularly as part of ongoing management rather than at the first sign of symptoms. This client may need additional education on the proper use of medications for Raynaud's disease.
C. "I will try to anticipate and avoid stressful situations when possible": Stress can exacerbate symptoms of Raynaud's disease by triggering vasospasm, so anticipating and avoiding stressful situations is a proactive strategy to help prevent attacks. This statement reflects an understanding of the importance of stress management in managing the condition.
D. "I will complete the smoking cessation program I started": Smoking is a significant risk factor for Raynaud's disease and can worsen symptoms by constricting blood vessels. Committing to a smoking cessation program demonstrates the client's recognition of the importance of lifestyle modifications in managing the condition.
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