MS2 Iggy chp 26 Flashcards


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1

A nurse is assessing a client who has suffered a nasal fracture which assessment would the nurse perform first

Airway patency

2

A nurse assesses a client who has a nasal fracture the client reports constant nasal drainage a headache and difficulty with vision what action would the nurse take next

Collect the nasal drainage on a piece of filter paper

3

A nurse teaches a client who has a supraglottic laryngectomy which technique would the nurse teach the client to prevent aspiration

Swallow twice while bearing down

4

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 lb (23kg) overweight

5

A nurse cares for a client who has hypertension that has not responded well to several medications the client states compliance is not an issue what action would the nurse take next

Assess the client for obstructive sleep apnea

6

A nurse cares for a client after radiation therapy for neck cancer the client reports extreme dry mouth what action by the nurse is most appropriate

Explain the that xerostomia may be a permanent side effect

7

A nurse cares for a client who had a partial laryngectomy 10 days ago the client states that all food tastes bland how would the nurse respond

This is normal after surgery what types of food do you like to eat

8

A nurse cares for a client who is scheduled for a total laryngectomy what action would the nurse take prior to surgery

Assist the client to choose a communication method

9

While assessing a client who has facial trauma the nurse auscultates stridor the client is anxious and restless what action would the nurse take first

Contact the primary health care provider and prepare for intubation

10

A nurse cares for a client who has packing inserted for posterior nasal bleeding what action would the nurse take first

Assess the clients airway

11

A nurse teaches a client to use a room humidifier after a laryngectomy which statement would the nurse include in this patients teaching

Make sure you clean the humidifier to prevent infection

12

A nurse is caring for a client who had a modified uvulopalatopharyngoplasty(modUPPP) earlier in the day for obstructive sleep apnea which assessment finding indicates that a priority goal has been met

Client is able to swallow own secretions without drooling

13

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place what actions would the nurse take(SATA)

Observe for clear drainage

Assess for signs of bleeding

Watch the client for frequent swallowing

ask the client to open his or her mouth

14

A nurse is teaching with obstructive sleep apnea(OSA) about the prescribed CPAP what information does the nurse include (SATA)

Once the delivery mask is adjusted do not loosen the straps

The CPAP provides pressure that holds your upper airway open

The humidification increases the risk of fungal infections

Be patient when using the system it can be frustrating at first

15

A nurse assesses a client who has facial trauma which assessment findings require immediate intervention(SATA)

Stridor

Ecchymosis behind the ear

16

A nurse teaches a client who is being discharged after a jaw wiring for a mandible fracture which statements would the nurse include in this patients teaching(SATA)

You will need to cut the wires if you start vomiting

Eat six soft or liquid meals each day while recovering

Use a waterpik for dental hygiene until you can brush again

Sleep in a semi-Fowler position after the surgery

17

A nurse is assessing clients on a rehabilitation unit which clients are at greatest risk for airway loss related to aspirated oral and nasopharyngeal secretions (SATA)

A 24 year old with a traumatic brain injury

A 58 year old getting radiation therapy

A 66 year old who is quadripelgic

An 80 year old who is aphasic

18

A nurse assesses a client who is at risk for neck cancer which symptoms would the nurse assess for (SATA)

Oral mucosa is gray or dark brown

Pain when drinking grapefruit juice

Oral lesions that are over 2 weeks old

Changes in the patients voice quality

19

A nurse teaches a client who has epistaxis and recently had his nasal packing removed which statements indicate that the client correctly understood the teaching (SATA)

Nasal Saline sprays will help to prevent rebleeding

I will wait at least 1 month before resuming weightlifting

I will apply a small amount of petroleum jelly to my nares

20

A nurse is teaching a community group about the long term effects of untreated sleep apnea what information does the nurse include

Hypertension

Stroke

Weight gain

Diabetes

Cognitive deficits

Pulmonary disease