Question

The client with Hodgkin's disease undergoes an excisional cervical lymph node

biopsy under local anesthesia. After the procedure, which does the nurse assess first?
1. Vital signs.
2. The incision.
3. The airway.
4. Neurologic signs.

Answer 1

The nurse should first assess the airway after a client undergoes an excisional cervical lymph node biopsy. The nurse can assess the airway by observing the client's respiratory rate, oxygen saturation levels, and assessing for any signs of airway obstruction or distress. the correct answer is 3. The airway.

Step-by-step explanation:

The nurse should first assess the airway after a client undergoes an excisional cervical lymph node biopsy. The airway is always a priority in any post-operative assessment to ensure the client's ability to breathe and maintain adequate oxygenation. The nurse can assess the airway by observing the client's respiratory rate, oxygen saturation levels, and assessing for any signs of airway obstruction or distress.

1. Vital signs: After assessing the airway, the nurse should then proceed to assess the client's vital signs, including heart rate, blood pressure, temperature, and respiratory rate. This will provide important information about the client's overall physiological status.
2. The incision: Once the airway and vital signs have been assessed, the nurse can then move on to assess the surgical incision for signs of bleeding, infection, or other complications. The nurse should observe the incision site for redness, swelling, drainage, or any signs of dehiscence or evisceration.
3. Neurologic signs: Lastly, the nurse should assess for any neurologic signs or symptoms, such as changes in mental status, motor or sensory deficits, or signs of increased intracranial pressure. This assessment is important to identify any potential complications or adverse effects from the procedure.