Nokea
A client who was in a motor vehicle accident has a fractured mandible. Surgery has been performed to immobilize the injury by wiring the jaw. In the immediate postoperative phase, the nurse should:
- A. Prevent nausea and vomiting.
- B. Maintain a patent airway.
- C. Provide frequent oral hygiene.
- D. Establish a way for the client to communicate.
Correct Answer: B
Rationale: Maintaining a patent airway is the priority in the immediate postoperative phase for a client with a wired jaw, as swelling or secretions could obstruct the airway. While the other interventions are important, airway management is the most critical.
You may also like to solve these questions
A hospice client's family asks how they will know when death is imminent. The nurse should explain that signs include:
- A. Increased energy and mobility.
- B. Cheyne-Stokes respirations.
- C. Improved blood pressure.
- D. Clear lung sounds.
Correct Answer: B
Rationale: Cheyne-Stokes respirations, characterized by alternating periods of apnea and deep breathing, are a common sign of imminent death.
A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time?
- A. Monitor daily weights and urine output.
- B. Permit unrestricted visitation by family and friends.
- C. Provide client education on medications and diet.
- D. Reduce pain and myocardial oxygen demand.
Correct Answer: D
Rationale: The client is experiencing an acute myocardial infarction, indicated by ST elevation and elevated troponin. Reducing pain and myocardial oxygen demand is critical to minimize further cardiac damage.
A client complaining of numbness from the back of his left buttock to the dorsum of his foot and big toe is scheduled to undergo a laminectomy. The operative consent form states, 'a left lumbar laminectomy of L3-4.' Which of the following should the nurse do next?
- A. Have the client sign the consent form.
- B. Call the surgeon.
- C. Change the consent form.
- D. Review the client's history.
Correct Answer: B
Rationale: The consent form must match the client's symptoms, which suggest L5-S1 involvement, not L3-4. The surgeon must clarify.
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?
- A. Limit fluid intake to 1,000 mL/day.
- B. Insert an indwelling urinary catheter.
- C. Establish a regular voiding schedule.
- D. Administer prophylactic antibiotics, as ordered.
Correct Answer: C
Rationale: A regular voiding schedule helps manage incontinence by promoting bladder emptying before urgency. Fluid restriction risks dehydration, indwelling catheters increase infection risk, and antibiotics are not preventive for incontinence.
Which of the following groups would benefit most from education regarding potential risk factors for melanoma?
- A. Adults older than age 35.
- B. Senior citizens who have been repeatedly exposed to the effects of ultraviolet A and ultraviolet B rays.
- C. Parents with children.
- D. Employees of a chemical factory.
Correct Answer: B
Rationale: Senior citizens with repeated exposure to UV rays are at the highest risk for melanoma due to cumulative skin damage. Education on risk factors like UV exposure is most beneficial for this group.