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.
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Related Questions
Correct Answer is A
Explanation
A. Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by alternating periods of hyperventilation followed by apnea. This respiratory pattern is often observed in clients with conditions affecting the central nervous system, such as brain injury or stroke.
B. Apneustic respirations: Apneustic respirations are characterized by prolonged, gasping inhalations followed by extremely short, ineffective exhalations. This pattern is associated with damage to the pons, a part of the brainstem.
C. Stridor: Stridor is a high-pitched, noisy breathing sound caused by turbulent airflow through a partially obstructed airway. It is not related to the described alternating pattern of hyperventilation and apnea.
D. Kussmaul respirations: Kussmaul respirations are deep, rapid respirations often seen in metabolic acidosis. They are not characterized by the alternating pattern described in the scenario.
Correct Answer is B
Explanation
A. Instruct the woman to call 911: This is a correct action, but it should be the second step after the nurse initiates first aid measures. Directing someone to call for emergency assistance is crucial, but immediate intervention to relieve the choking takes precedence.
B. The Heimlich maneuver involves abdominal thrusts and is the recommended technique for relieving choking in a conscious person. It is essential to act quickly and decisively to clear the airway.
C. Ask the partner if he can speak: If the person is unable to speak, cough, or breathe, it may indicate complete airway obstruction. The nurse should not delay intervention by asking if the person can speak but should immediately proceed with measures to relieve the choking.
D. Perform chest compressions: Chest compressions are not indicated for a conscious choking victim. Chest compressions are performed in the context of cardiopulmonary resuscitation (CPR) for an unconscious person with no pulse.
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