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 C
Explanation
A. "This test will help my provider adjust my warfarin dosages": aPTT is not typically used to monitor warfarin therapy. Instead, it is more commonly associated with monitoring heparin therapy.
B. "If my levels are too low, I am at an increased risk for bleeding": This statement is inaccurate. Low levels of clotting factors could lead to a prolonged aPTT, which might increase the risk of bleeding.
C. "It measures deficiencies in clotting factors."
Activated partial thromboplastin time (aPTT) is a laboratory test that evaluates the intrinsic pathway of the coagulation cascade. The aPTT measures the time it takes for a clot to form and reflects the activity of various clotting factors, including factors VIII, IX, XI, and XII. An elevated aPTT may indicate a deficiency or dysfunction of one or more clotting factors.
D. "I will need to skip breakfast until after the test is complete": There is no need for the client to skip breakfast before an aPTT test. The test is not affected by food intake.
Correct Answer is A
Explanation
A. Fatigue: Hypokalemia (low potassium levels) can lead to fatigue and weakness. Potassium is essential for proper muscle and nerve function, and a deficiency can result in muscle weakness and decreased energy levels.
B. Pitting edema: Pitting edema is more commonly associated with fluid retention, which can occur in heart failure. Hypokalemia is not typically a direct cause of pitting edema.
C. Dyspnea: Dyspnea (shortness of breath) is a symptom commonly associated with heart failure, and while potassium imbalance can affect cardiac function, it is not a specific manifestation of hypokalemia.
D. Oliguria: Oliguria (decreased urine output) is not a typical manifestation of hypokalemia. However, it can be associated with heart failure and other renal conditions.
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