Nokea
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.
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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 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 is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, 'How will this medication help me?' How should the nurse respond?
- A. This medication will treat your sleep apnea.
- B. This sedative will help you to sleep at night.
- C. This medication will treat your daytime restlessness.
- D. This analgesic will increase comfort while you sleep.
Correct Answer: C
Rationale: Modafinil is used to promote wakefulness in clients with narcolepsy or daytime sleepiness related to sleep apnea, addressing excessive daytime restlessness.
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 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.