Nokea
The nurse is caring for a client with an upper respiratory disorder. The client states they have a hacky, nonproductive cough, which wakens them during the night. Which over-the-counter medication would the nurse suggest to diminish the cough during the night?
- A. Diphenhydramine
- B. Dextromethorphan
- C. Pseudoephedrine
- D. Fluticasone
Correct Answer: B
Rationale: Dextromethorphan acts on the central nervous system to raise the cough threshold and dampen the cough reflex. Diphenhydramine is an antihistamine that relieves symptoms associated with allergies. Pseudoephedrine relieves nasalcongestion associated with sinusitis, colds, and allergies. Fluticasone reduces tissue edema.
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The nurse is providing tracheostomy care for a client. Place the following steps in the order the nurse should perform them.
- A. Position client in a supine or low Fowler position.
- B. Using a clean glove, remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle.
- C. Open the tracheostomy kit without contaminating the contents. Don sterile gloves- keep the dominant hand sterile. Pour hydrogen peroxide and normal saline into respective containers.
- D. Unlock the inner cannula by turning it counterclockwise. Remove it and place in hydrogen peroxide. Clean the inside and outside of the cannula with pipe cleaners.
- E. Rinse the cleaned cannula with normal saline. Tap the cannula and wipe the excess solution with sterile gauze.
- F. Replace the inner cannula and turn it clockwise within the outer cannula.
- G. Clean around the stoma with an applicator moistened with normal saline.
Correct Answer: C,A,B,D,E,G,F
Rationale: The nurse should position client in a supine or low Fowler position. Using a clean glove, the nurse should remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle. The nurse should then open the tracheostomy kit without contaminating the contents. The nurse should don sterile gloves, keeping the dominant hand sterile. Next, the nurse should pour hydrogen peroxide and normalsaline into respective containers. The nurse should then unlock the inner cannula by turning it counterclockwise, afterward removing it and placing it in hydrogen peroxide. The nurse should clean the inside and outside of the cannula with pipe cleaners. Next, the nurse should rinse the cleaned cannula with normal saline. The nurse should then tap the cannula and wipe the excess solution with sterile gauze. Next, the nurse should replace the inner cannula and turn it clockwise within the outer cannula. The nurseshould then clean around the stoma with an applicator moistened with normal saline.Next, the nurse should place a sterile dressing around the tracheostomy tube andchange the tracheostomy ties by placing the new ones on first and removing the soiled ones last. Finally, the nurse should tie the new ends securely, but not tightly, at theside of the neck. The nurse should perform hand hygiene before, during, and after the procedure.
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 with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?
- A. Copious mucous secretions
- B. Sudden restlessness
- C. Harsh cough
- D. Bilateral breath sounds present
Correct Answer: B
Rationale: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube.Bilateral breath sounds are an expected finding; the absence of bilateral breath sounds should be reported to the provider immediately.
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.
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.