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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.
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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.
A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this client's teaching?
- A. Add peppermint oil to the humidifier to relax the airway.
- B. Make sure you clean the humidifier to prevent infection.
- C. Keep the humidifier filled with water at all times.
- D. Use the humidifier when you sleep, even during daytime naps.
Correct Answer: B
Rationale: Cleaning the humidifier is critical to prevent infection from mold or bacteria. Peppermint oil is not recommended, and constant water filling or use during naps is unnecessary.
After teaching a client who is prescribed voice rest therapy for vocal cord polyps, a nurse assesses the client's understanding. Which statement indicates the client needs further teaching?
- A. I will stay away from smokers to minimize inhalation of secondhand smoke.
- B. I will whisper quietly to communicate during voice rest.
- C. I will drink at least three quarts of water each day to stay hydrated.
- D. I will use stool softeners to prevent straining.
Correct Answer: B
Rationale: The client with vocal cord polyps must avoid all vocalization, including whispering, to rest the voice fully. Staying hydrated, avoiding secondhand smoke, and using stool softeners are appropriate actions.
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 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?
- A. Check if the client is swallowing properly.
- B. This is normal after surgery. What types of food do you like to eat?
- C. I will ask the dietitian to change the consistency of the food in your diet.
- D. Notify the provider about potential nerve damage.
Correct Answer: B
Rationale: A partial laryngectomy can affect taste due to changes in the oral and pharyngeal anatomy. Acknowledging this as normal and exploring food preferences helps address the client's concern while promoting nutritional intake.