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 C

Explanation

A. At the beginning: Examining the tympanic membrane at the beginning of the physical examination may not be ideal because it disrupts the flow of the assessment. It's more logical to start with general observations and proceed to more specific areas of assessment.
B. Before auscultating the chest and abdomen: While examining the tympanic membrane before auscultating the chest and abdomen may seem reasonable, it's not the optimal sequence. The nurse should focus on assessing major body systems before proceeding to more specific areas, such as the ears.
C. At the end: This is the correct approach. After completing the assessment of major body systems, such as the cardiovascular, respiratory, and abdominal systems, the nurse can then proceed to examine the ears, including the tympanic membrane. This sequence ensures a systematic and organized assessment.
D. Before examining the head and neck: While examining the tympanic membrane before the head and neck may seem logical due to proximity, it's more practical to conduct a comprehensive head-to-toe assessment first before focusing on specific areas like the ears.

A. CD4 T cell count 180 cells/mm3 B. Platelets 150,000/mm3 C. WBC 5000 mm3 D. Positive Western blot test

Correct Answer is A

Explanation

A. CD4 T cell count 180 cells/mm3: In a client with HIV, monitoring the CD4 T cell count is crucial for assessing immune function and determining the progression of the disease. A CD4 T cell count of less than 200 cells/mm3 indicates severe immunosuppression and an increased risk of opportunistic infections, making it the priority laboratory value to monitor in this client.
B. Platelets 150,000/mm3: While platelet count is important for assessing clotting function, it is not the priority laboratory value in a client with HIV. Thrombocytopenia can occur in HIV but is often secondary to other factors such as medication side effects or opportunistic infections. However, a platelet count within the normal range of 150,000/mm3 is reassuring and does not require immediate intervention.
C. WBC 5000 mm3: White blood cell (WBC) count is essential for assessing overall immune function, but it is not the priority laboratory value in a client with HIV. A WBC count of 5000 mm3 is within the normal range and does not require urgent attention.
D. Positive Western blot test: While a positive Western blot test confirms HIV infection, it does not provide information about the client's current immune status or the need for immediate intervention. Confirmatory tests such as Western blot are important for diagnosis, but they do not provide ongoing monitoring of disease progression or immune function.

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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?

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