Nokea
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstruction?
- A. A 26-year-old woman who is 8 months pregnant.
- B. A 42-year-old man with gastroesophageal reflux disease.
- C. A 50-year-old woman who is 50 pounds overweight.
- D. A 73-year-old man with type 2 diabetes mellitus.
Correct Answer: C
Rationale: The client who is extremely overweight is at the highest risk for airway obstruction due to the increased likelihood of conditions like sleep apnea, which can cause airway obstruction during sleep.
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The client with vocal cord polypusis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration.
- A. Tilt the head back as far as possible when swallowing.
- B. Tuck the chin down when swallowing.
- C. Breathe slowly and deeply while swallowing.
- D. Keep the head very still and straight while swallowing.
Correct Answer: B
Rationale: Tucking the chin down during swallowing helps prevent aspiration by closing off the airway. Tilting the head back would increase the chance of aspiration. Breathing slowly or keeping the head still does not specifically reduce aspiration risk.
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.
A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first?
- A. Initiate Standard Precautions.
- B. Apply direct pressure.
- C. Sit the client upright.
- D. Loosely pack the nose with gauze.
Correct Answer: A
Rationale: The nurse should implement Standard Precautions and don gloves prior to completing the other actions to ensure safety and infection control.
A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first?
- A. Assess the client's pain level.
- B. Check the client's oxygen saturation.
- C. Teach the client about the causes of nasal bleeding.
- D. Make sure the string is taped to the client's cheek.
Correct Answer: D
Rationale: Ensuring the nasal packing string is taped to the client's cheek prevents dislodgement and maintains airway patency, which is the priority.
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.