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The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?
- A. Administer an over-the-counter decongestant.
- B. Use an anti-allergy medication to decrease rhinitis.
- C. Place a warm cloth over the sinus area of the forehead.
- D. Gently blow the nose to eliminate nasal secretions.
Correct Answer: A
Rationale: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opensthe nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best.
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The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?
- A. A ventilator
- B. A face mask
- C. A rigid shell
- D. A nasal cannula
Correct Answer: B
Rationale: A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device.
The nurse is an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factor(s) would the nurse be sure to include in the workshop? Select all that apply.
- A. Alcohol
- B. Age
- C. Tobacco
- D. Industrial pollutants
- E. Region of country lived in
Correct Answer: A,B,C,D
Rationale: Carcinogens, such as tobacco, alcobol, and industrial pollutants, are associated with laryngeal cancer. The age of the client is also a factor, with a higher incidence among those 65 years of age or older. Region of country lived in is notassociated with laryngeal cancer as a specific risk factor.
The nurse is caring for the client who presents to the clinic with hoarseness for 2 months. Further testing diagnoses laryngeal cancer with the treatment plan of a radical neck dissection. When reinforcing information provided by the physician, which nursing instruction is most correct?
- A. Laser surgery is a possibility with limited side effects.
- B. The physician removes lymph nodes, muscles and tissue.
- C. Once the tissue is removed, no further treatment is necessary.
- D. The client will be able to speak normally once the swelling subsides.
Correct Answer: B
Rationale: When the physician prescribes a radical neck dissection, the disease has extended beyond the larynx. The physician removes lymph nodes, muscle, and tissue. Laser surgery is completed for early lesions and does not have the ability to remove all of the structure needed. Chemotherapy and radiation is typically administered. Theclient will lose the ability to speak normally.
The nurse is presenting about upper respiratory infections at an educational event for a local community group. What should the nurse be sure to include regarding cold tablets containing first-generation antihistamines?
- A. They dilute the nasal secretions.
- B. They lead to frequent sinus drainage.
- C. They can cause urinary hesitancy.
- D. They prolong bleeding.
Correct Answer: C
Rationale: The nurse should include information about the side effect of urinary hesitancy with first-generation antihistamines. This class of drugs can also cause drowsiness and dry mouth. Aspirin prolongs bleeding.
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.