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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.
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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.
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 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.