Nokea
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.
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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 post-sinus surgery. When assessing the client, the nurse asks how many the nurse is holding up. Why does the nurse assess postoperative visual acuity?
- A. To assess possible hemorrhage
- B. To assess damage to the optic nerve
- C. To assess postoperative infection
- D. To assess impaired drainage
Correct Answer: B
Rationale: A client who has undergone a sinus surgery faces a serious risk of damage to the optic nerve. Therefore, the nurse assesses postoperative visual acuity by asking the client to identify the number of fingers displayed. To assess possible hemorrhage, the nurse observes the client for repeated swallowing. The nurse assesses for pain over the involved sinuses and not a postoperative infection or an impaired drainage.
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.
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 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.