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A nurse cares for a client with facial and neck tissue edema after facial trauma. Which action should the nurse take first?
- A. Contact the provider and prepare for intubation.
- B. Administer prescribed albuterol nebulizer therapy.
- C. Place the client in high-Fowler's position.
- D. Ask the client to perform deep-breathing exercises.
Correct Answer: A
Rationale: Facial and neck tissue edema can compromise airway patency. Immediate intubation may be necessary to ensure airway patency, making it the priority action.
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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 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.
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 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.