Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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 for signs of infection.
While assessing for signs of infection is important, ensuring a patent airway takes precedence immediately following surgery.
B. Assess for a patent airway.
This statement is correct. Assessing for a patent airway is the top priority in postoperative care to ensure the patient can breathe effectively.
C. Assess ability to clear oral secretions.
Assessing the ability to clear oral secretions is important, but it is secondary to ensuring a patent airway.
D. Assess for ability to communicate.
Assessing the ability to communicate is important, but it is not the immediate priority after surgical resection for oropharyngeal cancer.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 6. Take the full exam now
Full Explanation
Choice A reason:
While assessing for signs of infection is important, ensuring a patent airway takes precedence immediately following surgery.
Choice B reason:
This statement is correct. Assessing for a patent airway is the top priority in postoperative care to ensure the patient can breathe effectively.
Choice C reason:
Assessing the ability to clear oral secretions is important, but it is secondary to ensuring a patent airway.
Choice D reason:
Assessing the ability to communicate is important, but it is not the immediate priority after surgical resection for oropharyngeal cancer.
Similar Questions
A nurse is caring for a client who has acute pancreatitis.
Complete the following sentence.
When prioritizing client needs, the nurse should first address the
Full Explanation
-blood glucose level of 250 mg/dL, which indicates hyperglycemia and can worsen the inflammation of the pancreas
- hemoglobin level of 8 g/dL and hematocrit of 24%, which indicate anemia and can impair oxygen delivery to the tissues
A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?
A. Increased blood pressure
Increased blood pressure is not typically associated with gastrointestinal perforation; hypotension may be more indicative.
B. Hyperactive bowel sounds
Hyperactive bowel sounds may be present in various gastrointestinal conditions, but they are not specific to perforation.
C. Bradycardia
Bradycardia is not a typical sign of gastrointestinal perforation; tachycardia may be more indicative of this condition.
D. Sudden abdominal pain
This statement is correct. Sudden abdominal pain is a key indication of gastrointestinal perforation, and it should be monitored closely.
Full Explanation
Choice A reason:
Increased blood pressure is not typically associated with gastrointestinal perforation; hypotension may be more indicative.
Choice B reason:
Hyperactive bowel sounds may be present in various gastrointestinal conditions, but they are not specific to perforation.
Choice C reason:
Bradycardia is not a typical sign of gastrointestinal perforation; tachycardia may be more indicative of this condition.
Choice D reason:
This statement is correct. Sudden abdominal pain is a key indication of gastrointestinal perforation, and it should be monitored closely.
A patient's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather than ulcerative colitis, as the cause of the patient's signs and symptoms?
A. Severe diarrhea
Severe diarrhea can be a symptom of both Crohn's disease and ulcerative colitis and does not specifically indicate one over the other.
B. Involvement of the rectal mucosa
Involvement of the rectal mucosa is more indicative of ulcerative colitis rather than Crohn's disease, as Crohn's disease can affect any part of the digestive tract.
C. An absence of blood in stool
The presence or absence of blood in stool is not a definitive indicator of either Crohn's disease or ulcerative colitis, as both conditions can involve bleeding.
D. A pattern of distinct exacerbations and remissions
This statement is correct. A pattern of distinct exacerbations and remissions is more characteristic of Crohn's disease, whereas ulcerative colitis often presents with continuous, chronic symptoms.
Full Explanation
Choice A reason:
Severe diarrhea can be a symptom of both Crohn's disease and ulcerative colitis and does not specifically indicate one over the other.
Choice B reason:
Involvement of the rectal mucosa is more indicative of ulcerative colitis rather than Crohn's disease, as Crohn's disease can affect any part of the digestive tract.
Choice C reason:
The presence or absence of blood in stool is not a definitive indicator of either Crohn's disease or ulcerative colitis, as both conditions can involve bleeding.
Choice D reason:
This statement is correct. A pattern of distinct exacerbations and remissions is more characteristic of Crohn's disease, whereas ulcerative colitis often presents with continuous, chronic symptoms.