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A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?
- A. Assess ability to clear oral secretions.
- B. Assess for signs of infection.
- C. Assess for a patent airway.
- D. Assess for ability to communicate.
Correct Answer: C
Rationale: Postoperatively, the nurse assesses for a patent airway. The patients ability to manage secretions has a direct bearing on airway patency. However, airway patency is the overarching goal. This immediate physiologic need is prioritized over communication, though this is an important consideration. Infection is not normally a threat in the immediate postoperative period.
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A nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement?
- A. Keep the head of the bed lowered.
- B. Drink a cup of hot tea before bedtime.
- C. Avoid carbonated drinks.
- D. Eat a low-protein diet.
Correct Answer: C
Rationale: For a patient diagnosed with esophageal reflux disorder, the nurse should instruct the patient to keep the head of the bed elevated. Carbonated drinks, caffeine, and tobacco should be avoided. Protein limitation is not necessary.
A nurse is performing health education with a patient who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis?
- A. Ineffective Tissue Perfusion
- B. Impaired Skin Integrity
- C. Aspiration
- D. Imbalanced Nutrition: Less Than Body Requirements
Correct Answer: D
Rationale: Because digestion normally begins in the mouth, adequate nutrition is related to good dental health and the general condition of the mouth. Any discomfort or adverse condition in the oral cavity can affect a persons nutritional status. Dental caries do not typically affect the patients tissue perfusion or skin integrity. Aspiration is not a likely consequence of dental caries.
The nurse notes that a patient who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the most important consideration for the nurse when suctioning this patient?
- A. Avoid applying suction on or near the suture line.
- B. Position patient on the non operative side with the head of the bed down.
- C. Assess the patients ability to perform self-suctioning.
- D. Evaluate the patients ability to swallow saliva and clear fluids.
Correct Answer: A
Rationale: The nurse should avoid positioning the suction catheter on or near the graft suture lines. Application of suction in these areas could damage the graft. Self-suctioning may be unsafe because the patient may damage the suture line. Following a modified radical neck dissection with graft, the patient is usually positioned with the head of the bed elevated to promote drainage and reduce edema. Assessing viability of the graft is important but is not part of the suctioning procedure and may delay initiating suctioning. Maintenance of a patent airway is a nursing priority. Similarly, the patients ability to swallow is an important assessment for the nurse to make; however, it is not directly linked to the patients need for suctioning.
A nurse is caring for a patient who has just had a rigid fixation of a mandibular fracture. When planning the discharge teaching for this patient, what would the nurse be sure to include?
- A. Increasing calcium intake to promote bone healing
- B. Avoiding chewing food for the specified number of weeks after surgery
- C. Techniques for managing parenteral nutrition in the home setting
- D. Techniques for managing a gastrostomy
Correct Answer: B
Rationale: The patient who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake. Increased calcium intake will not have an appreciable effect on healing. Enteral and parenteral nutrition are rarely necessary.
A radial graft is planned in the treatment of a patients oropharyngeal cancer. In order to ensure that the surgery will be successful, the care team must perform what assessment prior to surgery?
- A. Assessing function of cranial nerves V, VI, and IX
- B. Assessing for a history of GERD
- C. Assessing for signs or symptoms of atherosclerosis
- D. Assessing the patency of the ulnar artery
Correct Answer: D
Rationale: If a radial graft is to be performed, an Allen test on the donor arm must be performed to ensure that the ulnar artery is patent and can provide blood flow to the hand after removal of the radial artery. The success of this surgery is not primarily dependent on CN function or the absence of GERD and atherosclerosis.