Nokea
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?
- A. Epistaxis, twice last week
- B. Aphonia following a football game
- C. Hoarseness for 2 weeks
- D. Laryngitis following a cold
Correct Answer: C
Rationale: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity.
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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.
The nurse is performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would the nurse ask the client about the use of herbal supplements?
- A. They produce anorexia.
- B. They impair the immune system.
- C. They may prolong bleeding.
- D. They lower high-density lipoprotein levels.
Correct Answer: C
Rationale: The nurse must find out the bleeding tendencies of clients scheduled for tonsillectomy and adenoidectomy. Therefore, the nurse asks the clients about any recent use of herbal supplements. The nurse must ask about the use of thesesupplements because they may prolong bleeding. A client may experience anorexia because of a diminished sense of taste and smell following a laryngectomy. Similarly, excess zinc impairs the immune system and lowers the levels of high-density lipoproteins. These symptoms are not caused by herbal supplements.
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.
The nurse is caring for a client diagnosed with coryza possibly from the rhinovirus. Vital signs are temperature: $101.2^{\circ} \mathrm{F}$, pulse: 72 beats/minute, respirations: 28 breaths/minute, blood pressure: $112 / 70$ $\mathrm{mm} \mathrm{Hg}$. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are coarse in the bases. Which afternoon assessment finding suggests the advancement to an infectious process?
- A. Achiness
- B. Headache
- C. Temperature rise
- D. Increased respiratory rate
Correct Answer: C
Rationale: Coryza refers to the common cold many times associated with a virus such as the rhinovirus. The nurse notes that the client is currently febrile. A rise in the temperature is interpreted that the client continues to have a sustained elevated temperature which suggests a bacterial infection. All viruses can include symptoms of achiness, headache, and an increase in the respiratory rate. Increased respiratory rate does not always indicate infection because it can be a sign of a multitude of other problems.
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.