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The nurse is caring for a client who is status post nasal polypectomy. What would the nurse instruct this client to report?
- A. Excessive swallowing
- B. Nasal stuffiness
- C. Diarrhea
- D. Coughing
Correct Answer: A
Rationale: The nurse inspects the nasal packing and dressings frequently for bleeding and asks the client to report excessive swallowing, which can indicate bleeding. Nasal stuffiness and diarrhea do not indicate postoperative bleeding. Coughing can loosen or expel scabs on the surgical wounds.
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The nurse is providing discharge instructions to a client diagnosed with postoperative tonsillectomy and adenoidectomy. Which discharge instruction(s) would the nurse include? Select all that apply.
- A. Postoperative bleeding most frequently occurs in the hours after surgery.
- B. Avoid carbonated fluids
- C. Gradually increase fluids then add soft foods.
- D. Apply an ice collar to the neck area.
- E. Gargle with warm saline water.
- F. Limit pain medications to the nighttime.
Correct Answer: B,C,D,E
Rationale: A client may be at risk for postoperative bleeding for several days following the surgical procedure as the scab may be removed from the surgical site early causing the bleeding. Clients should avoid carbonated beverages and citrus fluids or foods because these agents are caustic to the suture line. The client should gradually increase fluids from thin liquids to thick liquids then soft foods through the recovery process. Applying an ice collar and gargling with saline decreases swelling and aids in preventing infection. Pain medication would be appropriate throughout the day, not just at night.
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.
The nurse is receiving the post-tonsillectomy and post-adenoidectomy client in the postanesthesia care unit (PACU). The nurse aide is assisting the client from the stretcher to the bed. The client remains drowsy from anesthesia. In which position would the nurse instruct the nurse aide to place the client?
- A. On one side
- B. Supine
- C. Semi-Fowler's
- D. High-Fowler's
Correct Answer: A
Rationale: Upon receiving the client in the PACU, the client is drowsy and not fully conscious. A standard of care to prevent aspiration is to place the client lying on either side with an emesis basin to catch drainage. Laying the client is a supine position,semi-Fowler's position, or high-Fowler's position does not provide an easy exit for secretions as the client is recovering from the anesthesia.
A client had a tracheostomy two hours ago. The nurse assesses the client and finds the client's breathing is shallow, with a respiratory rate of 30 . The nurse notes increased mucus production around the tracheostomy and on the dressing. What is the priority nursing concern(s)? Select all that apply.
- A. Ineffective airway clearance
- B. Infection risk
- C. Knowledge deficiency
- D. Impaired gas exchange
- E. Altered body image perception
Correct Answer: A,D
Rationale: The client with a new tracheostomy tube has increased secretions, which may become dried and occlude or plug the airway, requiring frequent suctioning. Impaired gas exchange and airway clearance are priority nursing concerns. Infection, knowledge deficit, and altered body image are concerns, but not priorities.
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.