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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.
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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 registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.)
- A. A 32-year-old who had a radical neck dissection 6 hours ago.
- B. A 65-year-old who had a biopsy 2 days ago.
- C. A 55-year-old who needs discharge teaching after a laryngectomy.
- D. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer.
- E. An 80-year-old with esophageal cancer who is awaiting gastric tube placement.
Correct Answer: B,E
Rationale: The RN can delegate stable clients, such as the client 2 days post-biopsy and the client awaiting gastric tube placement, to the LPN. Clients who are 6 hours post-surgery or require teaching cannot be delegated.
A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretion? (Select all that apply.)
- A. A 24-year-old with a traumatic brain injury.
- B. A 36-year-old who fractured his left femur.
- C. A 30-year-old at risk for aspiration following radiation therapy.
- D. A 60-year-old who is quadriplegic and has a sacral ulcer.
- E. An 80-year-old who is aphasic after a cerebral vascular accident.
Correct Answer: A,C,D,E
Rationale: Clients with traumatic brain injury, aspiration risk post-radiation, quadriplegia, or aphasia are at risk for asphyxiation due to impaired ability to manage secretions. A fractured femur does not increase this risk.
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.
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.