Nokea
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.
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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.
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.
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
- A. Incrusted mucous membranes
- B. Hardened secretions
- C. Erosion of the trachea
- D. Noisy breathing
Correct Answer: D
Rationale: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following atracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.
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.