Nokea
The nurse is caring for a client in a physician's office whose $x$-ray of the sinus reveals exudate in the maxillary sinus. Which equipment must the nurse have present in the room?
- A. Otoscope
- B. Ophthalmoscope
- C. Irrigation equipment
- D. Tuning fork
Correct Answer: C
Rationale: The nurse would have sinus irrigation equipment available for the physician as saline irrigation of the maxillary sinus is done to remove exudate and promote drainage and avoid infection. An otoscope and tuning fork may be present in the room for further assessment. An ophthalmoscope is typically not needed.
You may also like to solve these questions
A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy?
- A. I must carry tissues with me.
- B. I must give up my love of pool aerobics.
- C. I will not be able to have the tracheostomy removed.
- D. Tell my spouse about it, I do not want to touch it.
Correct Answer: D
Rationale: Not wanting to participate in care and diverting the care to others indicates that the client has not accepted the tracheostomy. When evaluating teaching, the nurse should assess client and caregiver ability to provide home care. It is correct to carry tissues with the client because new tracheostomy tubes produce much mucous due to the irritation of the tube in the throat. Consideration needs to be arranged but being in a swimming pool may be completed as long as water does not surround the new tracheostomy. Stating the reality of not being able to remove the tracheostomy provides data that the client is accepting the tracheostomy as part of life.
The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply.
- A. A decreased respiratory rate
- B. Arterial blood gases reporting a $\mathrm{PaCO}_2$ of 48 and a $\mathrm{PaO}_2$ of 84
- C. Nasal flaring with abdominal retractions
- D. Administration of a corticosteroid inhaler for quick relief
- E. Lung sounds of wheezing
- F. Increased respiratory effort
Correct Answer: B,C,E,F
Rationale: The nurse would be calling to report signs of respiratory distress. This includes nasal flaring with abdominal retractions, stridor and an increased respiratory effort. Also arterial blood gases with an elevated $\mathrm{CO}_2$ and lower oxygen level indicates respiratory compromise. An increased respiratory rate occurs in respiratorycompromise. Administration of a corticosteroid decreases inflammation over a period of time.
The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, 'Elevate the head of the bed 45 degrees.' This assists in meeting which nursing goal?
- A. The client will have decreased pain.
- B. The client will remain alert and oriented.
- C. The client will have decreased edema.
- D. The client will have increased tissue perfusion.
Correct Answer: C
Rationale: Elevating the head of the bed 45 degrees when the client is fully awake decreases surgical edema and increases lung expansion. At this point in the recovery, elevating the head of the bed will not decrease the surgical pain as pain medication will be needed. Elevating the head of the bed will not affect mentation nor increase theblood supply.
The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently?
- A. Airway patency
- B. Level of consciousness
- C. Psychological status
- D. Pain level
Correct Answer: A
Rationale: The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation. The priorities are always airway, breathing, and then circulation.
A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis?
- A. Apply a moustache dressing.
- B. Provide a nasal splint.
- C. Apply direct continuous pressure.
- D. Place the client in a semi-Fowler's position.
Correct Answer: C
Rationale: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.