Nokea
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.
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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 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 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 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.