Respiratory Question #12

Question

The nurse is caring for a client following a radical neck dissection for laryngeal cancer. Which action by the nurse has the most priority during the immediate postoperative period?

Answers

  1. Perform frequent suctioning of the laryngectomy tube.
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  2. Monitor clear liquid diet for dysphagia.
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  3. Maintain low fowlers position with head immobile.
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  4. Monitor vital signs and lung sounds every shift.
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Overview

Explanation

Airway clearance and patency is critical following surgical neck dissection. Frequent suctioning will be required to ensure patency of the larygectomy tube (since secretions of blood and mucous can occlude the tube). Clear liquid diet is not part of immediate postoperative period and will require a swallow study about one week after surgery to determine if oral intake can occur. Maintaining fowler’s position helps airway, edema, and secretions; however, the recommended angle should be mid-fowlers, not low fowlers, and the head should not be immobile. Vital signs should be monitored frequently, not every shift.

Learning Outcomes

Test Taking Tip

Video Rationale