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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.
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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.
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 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.
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 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.