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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?
- A. Collect the nasal drainage into a piece of filter paper.
- B. Educating the client is blood loss.
- C. Perform a test focused on a neurologic examination.
- D. Patient is a client, face, face neck.
Correct Answer: A
Rationale: The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF, as a CSF leak places the client at risk for infection.
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A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture.
- A. You will need to cut the wires if you start vomiting.
- B. Eat soft or liquid meals each day while recovering.
- C. Irrigate your mouth every 2 hours to prevent infection.
- D. Sleep in a semi-Fowler's position after the surgery.
- E. Gargle with mouthwash that contains Benadryl once a day.
Correct Answer: A,B,C,D
Rationale: The client should be taught to cut wires in case of vomiting to prevent aspiration, eat soft or liquid meals, irrigate the mouth to prevent infection, and sleep in a semi-Fowler's position to reduce aspiration risk. Benadryl mouthwash is not indicated for this condition.
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?
- A. Ask the client to gargle with mouthwash containing lidocaine.
- B. Administer prescribed intravenous pain medications.
- C. Explain that soreness is normal and will improve in a couple days.
- D. Assess the client's neck for redness and swelling.
Correct Answer: A
Rationale: Mouthwashes and throat sprays containing a local anesthetic like lidocaine can provide relief from a sore throat after radiation therapy. Intravenous pain medications may be used if local anesthetics are unsuccessful. Explaining that soreness is normal or assessing the neck does not directly address the client's discomfort.
A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?
- A. Facial pain
- B. Vital signs
- C. Bone displacement
- D. Airway patency
Correct Answer: D
Rationale: A patent airway is the priority. The nurse first should make sure that the airway is patent and then should determine whether the client is in pain and whether bone displacement or blood loss has occurred.
A nurse assesses a client who reports waking up, feeling very tired, even after 4 hours of good sleep. Which action should the nurse take first?
- A. Assess for sleep apnea.
- B. Refer to a sleep specialist.
- C. Review the client's medication list.
- D. Encourage increased sleep duration.
Correct Answer: A
Rationale: The client's symptoms suggest possible sleep apnea, which can cause fatigue despite adequate sleep duration. Assessing for sleep apnea is the priority to identify the underlying cause and guide further management.
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.)
- A. Observe for clear drainage.
- B. Assess for signs of bleeding.
- C. Perform a neurologic examination.
- D. Monitor vital signs.
Correct Answer: A,B,C,D
Rationale: The nurse should observe for clear drainage (possible CSF leak), assess for bleeding, perform a neurologic examination due to the risk of skull fracture, and monitor vital signs to ensure stability.