Management of Care Q 11

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A newly admitted client diagnosed with Hodgkin’s disease undergoes an excisional cervical lymph node biopsy under local anesthesia. What does the nurse assess first after the procedure?

  

     A. Vital signs

     B. Incision site

     C. Airway

     D. Level of consciousness

    

    

Correct Answer: C. Airway

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Assessing for an open airway is the priority. The procedure involves the neck, the anesthesia may have affected the swallowing reflex or the inflammation may have closed in on the airway leading to ineffective air exchange. When the numbness wears off, the throat may feel scratchy for several days. After the test, the cough reflex will return in 1 to 2 hours. Then the client may eat and drink normally.

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Option A: The vital signs should be assessed after the procedure, but this may come after assessing the airway first. Infection is relatively rare and can be treated with antibiotics. Numbness can occur if the biopsy is done near nerves. Any numbness typically disappears within a couple of months.

Option B: The incision site should be assessed regularly, but this would not be the priority after the procedure. The patient should contact the physician if any redness, increased swelling, or increased pain develops at the surgery site. Patients may shower or bathe normally. The patient may get water on the incision. If there are stitches, they may get wet. If there is a plastic bandage over the incision, the patient may get this wet.

Option D: The client has only undergone local anesthesia, his level of consciousness should not be a cause of concern. Pain and tenderness can last for a few days after a biopsy. Once the client gets home, he should keep the biopsy site clean and dry at all times. The doctor may ask the client to avoid showers or baths for a couple of days after the surgery.

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