A client has returned from the surgical suite following surgery for a fractured mandible with intermaxillary fixation. Which of the following actions is the priority for the nurse to take?

Correct Answer: A

Rationale: The correct answer is A: Prevent aspiration. This is the priority because with intermaxillary fixation, the client is unable to open their mouth, increasing the risk of aspiration. Aspiration can lead to serious complications, such as pneumonia. Ensuring the client's airway is clear and they are able to breathe properly should be the top priority. Summary: - B: Ensuring adequate nutrition can be important, but preventing aspiration takes precedence. - C: Promoting oral hygiene is important but not as urgent as preventing aspiration. - D: Relieving the client's pain is essential, but ensuring their safety from aspiration is the priority.

Correct Answer: D

Rationale: Agoraphobia specifically refers to the fear of being in public spaces or situations where escape might be difficult.

Correct Answer: B

Rationale: The correct answer is B: Continuous bubbling in the water-seal chamber. Continuous bubbling in the water-seal chamber indicates an air leak in the system, which can lead to lung collapse. The water-seal chamber should have intermittent bubbling during exhalation but should not bubble continuously. Constant bubbling in the suction-control chamber (A) is expected and indicates proper suction is being applied. Bloody drainage in the collection chamber (C) is common in the immediate postoperative period. Fluid-level fluctuations in the water-seal chamber (D) can be normal due to changes in intrathoracic pressure.

Correct Answer: D

Rationale: The correct answer is D: Perform pre-oxygenation prior to suctioning. In this scenario, the increase in heart rate and irregularity could be due to hypoxia resulting from suctioning. Pre-oxygenation helps to ensure adequate oxygenation before the procedure, preventing hypoxia-induced dysrhythmias. By providing oxygen before suctioning, the nurse can minimize the risk of further complications. Choice A (Obtain a cardiology consult) is incorrect because immediate action is required to address the potential hypoxia, which can be managed by pre-oxygenation. Choice B (Suction the client less frequently) is incorrect as it does not address the immediate concern of potential hypoxia leading to dysrhythmias. Choice C (Administer an antidysrhythmic medication) is incorrect as it is not the initial intervention needed in this situation; addressing the underlying cause of potential hypoxia is essential before considering antidysrhythmic medications.

Correct Answer: B

Rationale: Many nurses advocate CAM because it aligns with a holistic view of health, considering physical, emotional, and spiritual aspects, as stated in option B.