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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. RBC (Red Blood Cells): ITP primarily affects platelet levels, not red blood cells. Therefore, red blood cell counts are not typically decreased in ITP.

B. Platelets: This is the correct answer. ITP is characterized by a low platelet count due to immune-mediated destruction of platelets. A decreased platelet count can lead to an increased risk of bleeding.

C. Granulocytes: While ITP primarily affects platelets, it does not have a direct impact on granulocyte counts. Granulocytes are a type of white blood cell.

D. WBC (White Blood Cells): ITP primarily affects platelets, not white blood cells. Therefore, white blood cell counts are not typically decreased in ITP.

A. "The medication can take up to 15 minutes to take effect." B. "Place the blet under your tongue, and then take a small sip of water." C. "Avoid taking the medication prior to exercising." D. "Stop taking the medication and notify your provider if you develop a headache.

Correct Answer is B

Explanation

A. "The medication can take up to 15 minutes to take effect." - This statement is not accurate, sublingual nitroglycerin works rapidly and often provides relief within a few minutes.

B. Sublingual nitroglycerin is administered by placing the tablet under the tongue, and it should be allowed to dissolve or be absorbed directly into the bloodstream through the mucous membranes. It is not swallowed or chewed. The small sip of water can help facilitate the dissolving process.

C. "Avoid taking the medication prior to exercising." - This statement is not accurate. Nitroglycerin can be taken before anticipated exertion or activities that may trigger angina to prevent anginal episodes during physical activity.

D. "Stop taking the medication and notify your provider if you develop a headache." - While headaches are a common side effect of nitroglycerin, they are generally transient and not a reason to stop taking the medication. Persistent or severe headaches should be reported to the healthcare provider.

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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?

Nursing Test Bank

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