A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?
Tissue integrity
Pain severity
Airway patency
Wound drainage
The Correct Answer is C
A. Tissue integrity: While assessing tissue integrity is important, ensuring airway patency takes precedence in the immediate postoperative period, especially following a procedure involving the larynx. Maintaining a patent airway is a critical priority.
B. Pain severity: Pain assessment is important, but it is not the primary concern immediately postoperatively in the context of a partial laryngectomy. Airway patency is of higher priority.
C. Airway patency: This is the correct answer. Following a partial laryngectomy, there may be concerns related to airway compromise due to the surgical procedure. The nurse should assess the airway first to ensure there are no obstructions or complications affecting the client's ability to breathe.
D. Wound drainage: While assessing wound drainage is important for monitoring surgical sites, it is not the first priority in the immediate postoperative period following a partial laryngectomy. Airway patency is a more critical concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A friction rub:A friction rub is a sound caused by the rubbing of inflamed pericardial layers and is not classified as a heart sound like S1 or S2. It is unrelated to the sequence of heart sounds.
B. A split second heart sound S₂:A split S₂ occurs during the closure of the aortic and pulmonary valves and is heard after S1, not before.
C. The third heart sound (S3):S3, or the ventricular gallop, occurs shortly after S2 during early diastole and indicates rapid ventricular filling. It is not heard before S1.
D. The fourth heart sound (S4):S4, known as the "atrial gallop," occurs just before S1 during atrial contraction. It is associated with a stiff or hypertrophied ventricle and is often indicative of underlying heart disease, especially in older adults.
Correct Answer is A
Explanation
A. Smoking cessation: Chronic bronchitis is often associated with smoking and exposure to tobacco smoke. The most effective preventive measure for chronic bronchitis is to quit smoking and avoid exposure to secondhand smoke. Smoking cessation not only prevents chronic bronchitis but also improves overall respiratory health.
B. Regular moderate exercise: While regular exercise is beneficial for overall health, it is not specifically cited as a primary preventive measure for chronic bronchitis. However, exercise can contribute to overall respiratory health and well-being.
C. Maintenance of ideal weight: Maintaining an ideal weight is important for overall health, but it is not identified as a specific preventive measure for chronic bronchitis.
D. Annual influenza immunization: Influenza immunization is important for preventing influenza (flu) and its complications. While individuals with chronic bronchitis may be at increased risk for respiratory infections, annual influenza immunization is not a direct preventive measure for chronic bronchitis itself.
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