Nokea
A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis?
- A. Apply a moustache dressing.
- B. Provide a nasal splint.
- C. Apply direct continuous pressure.
- D. Place the client in a semi-Fowler's position.
Correct Answer: C
Rationale: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.
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The nurse is caring for a client in a physician's office whose $x$-ray of the sinus reveals exudate in the maxillary sinus. Which equipment must the nurse have present in the room?
- A. Otoscope
- B. Ophthalmoscope
- C. Irrigation equipment
- D. Tuning fork
Correct Answer: C
Rationale: The nurse would have sinus irrigation equipment available for the physician as saline irrigation of the maxillary sinus is done to remove exudate and promote drainage and avoid infection. An otoscope and tuning fork may be present in the room for further assessment. An ophthalmoscope is typically not needed.
The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?
- A. Develop an alternate method of communication.
- B. Encourage oral nutrition on the second postoperative day.
- C. Maintain the client in a low-Fowler's position.
- D. Assess the tracheostomy cuff for leaks.
Correct Answer: A
Rationale: The client with a total laryngectomy is not able to speak. Communication needs to be established using an alternate method. The client typically has difficulty with swallowing due to edema in the immediate postoperative period. Alternate forms of nutrition are used. The tracheostomy cuff is often deflated for periods of time. The head of the bed is maintained in a semi-Fowler's position to decrease edema.
A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy?
- A. I must carry tissues with me.
- B. I must give up my love of pool aerobics.
- C. I will not be able to have the tracheostomy removed.
- D. Tell my spouse about it, I do not want to touch it.
Correct Answer: D
Rationale: Not wanting to participate in care and diverting the care to others indicates that the client has not accepted the tracheostomy. When evaluating teaching, the nurse should assess client and caregiver ability to provide home care. It is correct to carry tissues with the client because new tracheostomy tubes produce much mucous due to the irritation of the tube in the throat. Consideration needs to be arranged but being in a swimming pool may be completed as long as water does not surround the new tracheostomy. Stating the reality of not being able to remove the tracheostomy provides data that the client is accepting the tracheostomy as part of life.
The nurse is caring for a client diagnosed with coryza possibly from the rhinovirus. Vital signs are temperature: $101.2^{\circ} \mathrm{F}$, pulse: 72 beats/minute, respirations: 28 breaths/minute, blood pressure: $112 / 70$ $\mathrm{mm} \mathrm{Hg}$. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are coarse in the bases. Which afternoon assessment finding suggests the advancement to an infectious process?
- A. Achiness
- B. Headache
- C. Temperature rise
- D. Increased respiratory rate
Correct Answer: C
Rationale: Coryza refers to the common cold many times associated with a virus such as the rhinovirus. The nurse notes that the client is currently febrile. A rise in the temperature is interpreted that the client continues to have a sustained elevated temperature which suggests a bacterial infection. All viruses can include symptoms of achiness, headache, and an increase in the respiratory rate. Increased respiratory rate does not always indicate infection because it can be a sign of a multitude of other problems.
The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose?
- A. CBC with differential
- B. Transillumination of the sinus
- C. Nasal culture
- D. Magnetic resonance imaging (MRI)
Correct Answer: B
Rationale: Transillumination and $x$-rays of the sinuses may show a change in the shape of or confirms that there is fluid in the sinus cavity. CBC with differential can note an elevated white blood cell count but not confirm fluid in the sinus cavity. A nasal culture can note bacteria in the nares. An MRI is an expensive procedure which is not typically prescribed for a potential infection and not specifically ordered to identify fluid in thesinus cavity.