A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?
Airway patency
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?
Collect the nasal drainage on a piece of filter paper.
A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first?
Ask the client if he or she has ever been evaluated for sleep apnea.
A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration?
Tuck the chin down when swallowing.
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?
A 55-year-old woman who is 50 pounds overweight
After teaching a client who is prescribed voice rest therapy for vocal cord polyps, a nurse assesses the clients understanding. Which statement indicates the client needs further teaching?
When I speak, I will whisper rather than use a normal tone of voice.
A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first?
Initiate Standard Precautions.
A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first?
Ask the client to gargle with mouthwash containing lidocaine.
A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond?
This is normal after surgery. What types of food do you like to eat?
A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery?
Assist the client to choose a communication method.
While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?
Contact the provider and prepare for intubation.
A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, How will this medication help me? How should the nurse respond?
This medication will promote daytime wakefulness.
A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first?
Make sure the string is taped to the clients cheek.
A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this clients teaching?
Make sure you clean the humidifier to prevent infection.
A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.)
Observe for clear drainage.
Assess for signs of bleeding.
Watch the client for frequent swallowing.
Ask the client to
open his or her mouth
A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.)
Hypertension
Leukemia
Cocaine use
A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.)
Stridor
Ecchymosis behind the ear
A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.)
A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago
An 88-year-old with esophageal cancer who is awaiting gastric tube placement
A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this clients teaching? (Select all that apply.)
You will need to cut the wires if you start vomiting.
Eat six
soft or liquid meals each day while recovering.
Irrigate your mouth every 2 hours to prevent infection.
Sleep
in a semi-Fowlers position after the surgery.
A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.)
A 24-year-old with a traumatic brain injury
A 58-year-old at risk for aspiration following radiation therapy
A 66-year-old who is a quadriplegic and has a sacral ulcer
An
80-year-old who is aphasic after a cerebral vascular accident