A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make?

Correct Answer: B

Rationale: The correct answer is B: "Keep wire cutters with you at all times." This is the priority statement because in the event of an emergency, such as airway obstruction or trauma, quick access to wire cutters is crucial to ensure timely removal of the jaw fixation wires. Without immediate access to wire cutters, the client may suffer serious complications. Incorrect choices: A: "We can teach you some relaxation techniques to minimize your pain." - While pain management is important, it is not the priority in this situation where the immediate risk is airway compromise. C: "Use a water pick device to keep your teeth clean." - Oral hygiene is important but not as critical as ensuring access to wire cutters for emergency situations. D: "Consume a high-protein, liquid diet." - Nutrition is important for healing but is not as time-sensitive as having wire cutters readily available in case of an emergency.

Correct Answer: C

Rationale: The correct answer is C: Movement of the ET tube into the right main bronchus. When the nurse observes absence of left-sided chest wall expansion, it indicates that the ET tube may have moved into the right main bronchus. This can lead to inadequate ventilation of the left lung, causing unilateral chest wall expansion. The other choices are incorrect because: A) Blockage by the tongue would not result in unilateral chest wall expansion. B) Passage into the esophagus would lead to improper ventilation but not specifically affect one side of the chest. D) Infection of the vocal cords would not directly cause unilateral chest wall expansion.

Correct Answer: B

Rationale: The correct action is to administer the abdominal thrust maneuver (Heimlich maneuver) first to attempt to dislodge the foreign body. This is the priority intervention when a conscious client is experiencing airway obstruction. Inserting an oral airway (Choice A) may worsen the obstruction. Turning the client to the side (Choice C) does not directly address the airway obstruction. Performing a blind finger sweep (Choice D) is not recommended as it can push the object further down the airway. Administering the abdominal thrust maneuver is the most effective and safest initial intervention to clear the airway obstruction.

Correct Answer: A

Rationale: The correct answer is A: Evaluate chest expansion. This is the priority action because it assesses the client's airway and breathing, which are critical for survival. Checking chest expansion helps to identify any potential respiratory compromise or underlying lung injuries. Assessing pupillary response (B) and capillary refill (C) are important, but they are secondary to ensuring adequate oxygenation. Checking the client's orientation to place and time (D) is important for neurological assessment but is not as critical as assessing airway and breathing in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Count the respiratory rate. This is the priority intervention because anaphylaxis can lead to severe respiratory distress due to airway swelling or bronchoconstriction. Counting the respiratory rate helps to quickly assess the client's breathing status and detect any signs of respiratory distress. Inserting an IV line (choice A) may be necessary for administering medications, but assessing the respiratory rate takes precedence. Administering oxygen (choice C) is important but should follow assessing the respiratory rate. Preparing equipment for intubation (choice D) is a later intervention if respiratory distress worsens.