Nokea
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.
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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 emergency department nurse is assessing a client following a motor vehicle accident. The nurse notes facial deformities with swelling and bleeding and a clear drainage coming from the nares. Which diagnostic test is completed to determine if the clear drainage is cerebrospinal fluid?
- A. Draw a serum CBC
- B. Test fluid with a Nitrazine paper
- C. Test fluid with a Dextrostix
- D. Perform a glucometer check
Correct Answer: C
Rationale: When clear drainage is observed from the nares of a client, a Dextrostix is used to determine the presence of glucose which is present in cerebrospinal fluid. A serum CBC would provide information on red and white blood cell count. A low red blood cell count is may be found due to hemorrhage that has occurred. Nitrazine paper is under to assess vaginal secretions for the presence of amniotic fluid. A glucometercheck will provide information on serum glucose, not the glucose level in the cerebrospinal fluid.
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.
A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first?
- A. Call for the registered nurse to reinsert the tube.
- B. Place a dilator in the stoma to maintain the opening.
- C. Cover the tracheostomy site with a sterile gauze to prevent infection.
- D. Transfer the client to the emergency department.
Correct Answer: B
Rationale: If the tracheostomy tube becomes dislodged, a dilator is initially placed to hold the edges of the stoma apart until a physician is able to reinsert the tube. A tracheal tube must never be forced back into place. Covering the tracheostomy sitewith gauze can obstruct the stoma, decreasing ventilation. If needed, transporting the client to the emergency department may occur but not until the airway is stabilized.
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.