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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.
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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 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.
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.
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?
- A. Collect the nasal drainage into a piece of filter paper.
- B. Educating the client is blood loss.
- C. Perform a test focused on a neurologic examination.
- D. Patient is a client, face, face neck.
Correct Answer: A
Rationale: The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF, as a CSF leak places the client at risk for infection.
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.