Question 1
Regular
A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?
Correct!
Incorrect
The correct answer is: D
Rationale
Airway patency. Assessing airway patency is crucial following a nasal fracture, as obstruction can occur due to swelling or blood. Ensuring the airway is clear prevents further complications and prioritizes the client's safety.
A: Facial pain. While assessing for facial pain is important, it is secondary to ensuring that the airway is unobstructed and functioning properly after a nasal injury.
B: Vital signs. Although monitoring vital signs is essential in overall patient assessment, it does not address immediate concerns regarding airway obstruction following a nasal fracture.
C: Bone displacement. Evaluating bone displacement can provide valuable information, yet it does not take precedence over verifying that the airway remains open and free from obstruction.
Correct Answer: D
Rationale: Airway patency. Assessing airway patency is crucial following a nasal fracture, as obstruction can occur due to swelling or blood. Ensuring the airway is clear prevents further complications and prioritizes the client's safety.
A: Facial pain. While assessing for facial pain is important, it is secondary to ensuring that the airway is unobstructed and functioning properly after a nasal injury.
B: Vital signs. Although monitoring vital signs is essential in overall patient assessment, it does not address immediate concerns regarding airway obstruction following a nasal fracture.
C: Bone displacement. Evaluating bone displacement can provide valuable information, yet it does not take precedence over verifying that the airway remains open and free from obstruction.
Question 2
Regular
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?
Correct!
Incorrect
The correct answer is: A
Rationale
Collect the nasal drainage into a piece of filter paper. This action helps determine the nature of the drainage, distinguishing between cerebrospinal fluid and other types, which is critical in assessing potential complications from the fracture.
B: Educating the client is blood loss. While education is important, assessing the nasal drainage provides immediate clinical information necessary for evaluating potential complications from the fracture.
C: Perform a test focused on a neurologic examination. Although a neurologic examination is relevant, it should follow the immediate assessment of nasal drainage to gauge if there is cerebrospinal fluid involvement.
D: Patient is a client, face, face neck. This option lacks clarity and does not address the specific needs of the client with a nasal fracture and associated symptoms.
Correct Answer: A
Rationale: Collect the nasal drainage into a piece of filter paper. This action helps determine the nature of the drainage, distinguishing between cerebrospinal fluid and other types, which is critical in assessing potential complications from the fracture.
B: Educating the client is blood loss. While education is important, assessing the nasal drainage provides immediate clinical information necessary for evaluating potential complications from the fracture.
C: Perform a test focused on a neurologic examination. Although a neurologic examination is relevant, it should follow the immediate assessment of nasal drainage to gauge if there is cerebrospinal fluid involvement.
D: Patient is a client, face, face neck. This option lacks clarity and does not address the specific needs of the client with a nasal fracture and associated symptoms.
Question 3
Regular
A nurse assesses a client who reports waking up, feeling very tired, even after 4 hours of good sleep. Which action should the nurse take first?
Correct!
Incorrect
The correct answer is: A
Rationale
Assess for sleep apnea.
This option is appropriate as sleep apnea is a common disorder that can lead to excessive daytime fatigue despite adequate sleep duration. Identifying this condition can significantly impact the client's overall health and treatment plan, making it a priority assessment for the nurse.
B: Refer to a sleep specialist. Immediate assessment is vital before considering a referral, as the nurse should first gather information to identify potential causes of the client's fatigue.
C: Review the client's medication list. While medications can influence sleep quality, assessing for sleep apnea directly addresses the client's reported symptoms and is crucial for determining the underlying issue first.
D: Encourage increased sleep duration. Suggesting more sleep does not resolve the client’s fatigue, especially when the reported sleep duration seems adequate; the nurse must first investigate possible sleep disorders.
Correct Answer: A
Rationale: Assess for sleep apnea.
This option is appropriate as sleep apnea is a common disorder that can lead to excessive daytime fatigue despite adequate sleep duration. Identifying this condition can significantly impact the client's overall health and treatment plan, making it a priority assessment for the nurse.
B: Refer to a sleep specialist. Immediate assessment is vital before considering a referral, as the nurse should first gather information to identify potential causes of the client's fatigue.
C: Review the client's medication list. While medications can influence sleep quality, assessing for sleep apnea directly addresses the client's reported symptoms and is crucial for determining the underlying issue first.
D: Encourage increased sleep duration. Suggesting more sleep does not resolve the client’s fatigue, especially when the reported sleep duration seems adequate; the nurse must first investigate possible sleep disorders.
Question 4
Regular
The client with vocal cord polypusis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration.
Correct!
Incorrect
The correct answer is: B
Rationale
B: Tuck the chin down when swallowing. This technique promotes a safer swallowing mechanism by narrowing the airway, thereby reducing the risk of aspiration for clients with vocal cord polypusis.
A: Tilt the head back as far as possible when swallowing. This position can inadvertently open the airway wider, increasing the likelihood of food or liquid entering the trachea, leading to aspiration.
C: Breathe slowly and deeply while swallowing. Although breathing techniques are beneficial, they do not specifically address the mechanical aspects of swallowing that can prevent aspiration in those with vocal cord issues.
D: Keep the head very still and straight while swallowing. Maintaining a rigid head position does not facilitate the optimal alignment of swallowing structures, which is crucial for preventing aspiration during the process.
Correct Answer: B
Rationale: B: Tuck the chin down when swallowing. This technique promotes a safer swallowing mechanism by narrowing the airway, thereby reducing the risk of aspiration for clients with vocal cord polypusis.
A: Tilt the head back as far as possible when swallowing. This position can inadvertently open the airway wider, increasing the likelihood of food or liquid entering the trachea, leading to aspiration.
C: Breathe slowly and deeply while swallowing. Although breathing techniques are beneficial, they do not specifically address the mechanical aspects of swallowing that can prevent aspiration in those with vocal cord issues.
D: Keep the head very still and straight while swallowing. Maintaining a rigid head position does not facilitate the optimal alignment of swallowing structures, which is crucial for preventing aspiration during the process.
Question 5
Regular
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstruction?
Correct!
Incorrect
The correct answer is: C
Rationale
A 50-year-old woman who is 50 pounds overweight is at greatest risk for development of obstruction. Obesity can lead to increased intra-abdominal pressure, which heightens the likelihood of gastrointestinal obstructions due to compressed organs and altered motility, presenting significant concern for healthcare providers monitoring at-risk patients in a medical-surgical setting.
A: A 26-year-old woman who is 8 months pregnant. While pregnancy can lead to physical changes, the risk of obstruction primarily relates to increased body weight rather than gestational factors alone.
B: A 42-year-old man with gastroesophageal reflux disease. GERD primarily affects the esophagus and does not directly correlate with mechanical obstructions in the gastrointestinal tract, focusing instead on reflux symptoms.
D: A 73-year-old man with type 2 diabetes mellitus. Although diabetes can complicate gastrointestinal function, it does not inherently increase the risk for obstruction as significantly as obesity does, especially in this context.
Correct Answer: C
Rationale: A 50-year-old woman who is 50 pounds overweight is at greatest risk for development of obstruction. Obesity can lead to increased intra-abdominal pressure, which heightens the likelihood of gastrointestinal obstructions due to compressed organs and altered motility, presenting significant concern for healthcare providers monitoring at-risk patients in a medical-surgical setting.
A: A 26-year-old woman who is 8 months pregnant. While pregnancy can lead to physical changes, the risk of obstruction primarily relates to increased body weight rather than gestational factors alone.
B: A 42-year-old man with gastroesophageal reflux disease. GERD primarily affects the esophagus and does not directly correlate with mechanical obstructions in the gastrointestinal tract, focusing instead on reflux symptoms.
D: A 73-year-old man with type 2 diabetes mellitus. Although diabetes can complicate gastrointestinal function, it does not inherently increase the risk for obstruction as significantly as obesity does, especially in this context.
Question 6
Regular
After teaching a client who is prescribed voice rest therapy for vocal cord polyps, a nurse assesses the client's understanding. Which statement indicates the client needs further teaching?
Correct!
Incorrect
The correct answer is: B
Rationale
During voice rest, whispering is not advisable as it can strain the vocal cords, counteracting the purpose of the therapy. Effective communication methods must be employed that do not involve vocal strain.
A: I will stay away from smokers to minimize inhalation of secondhand smoke. Avoiding secondhand smoke is essential for protecting the vocal cords and promoting healing during therapy.
C: I will drink at least three quarts of water each day to stay hydrated. Staying hydrated is vital for vocal cord health and aids in recovery, making this statement beneficial.
D: I will use stool softeners to prevent straining. Preventing straining during bowel movements is important for overall health and can help avoid additional stress on the body during recovery.
Correct Answer: B
Rationale: During voice rest, whispering is not advisable as it can strain the vocal cords, counteracting the purpose of the therapy. Effective communication methods must be employed that do not involve vocal strain.
A: I will stay away from smokers to minimize inhalation of secondhand smoke. Avoiding secondhand smoke is essential for protecting the vocal cords and promoting healing during therapy.
C: I will drink at least three quarts of water each day to stay hydrated. Staying hydrated is vital for vocal cord health and aids in recovery, making this statement beneficial.
D: I will use stool softeners to prevent straining. Preventing straining during bowel movements is important for overall health and can help avoid additional stress on the body during recovery.
Question 7
Regular
A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first?
Correct!
Incorrect
The correct answer is: A
Rationale
A: Initiate Standard Precautions.
Implementing Standard Precautions is essential to protect both the nurse and client from potential infections while managing epistaxis. This foundational step ensures safety before proceeding with any interventions.
B: Apply direct pressure. Direct pressure is a common approach for controlling bleeding, but it should be done after ensuring adequate precautions are in place to prevent cross-contamination.
C: Sit the client upright. While sitting upright can help reduce blood flow to the nose, it doesn't address the critical need for safety measures when dealing with potential pathogens.
D: Loosely pack the nose with gauze. This intervention may provide temporary relief, yet it is vital to first establish a safe environment through Standard Precautions before undertaking any invasive measures.
Correct Answer: A
Rationale: A: Initiate Standard Precautions.
Implementing Standard Precautions is essential to protect both the nurse and client from potential infections while managing epistaxis. This foundational step ensures safety before proceeding with any interventions.
B: Apply direct pressure. Direct pressure is a common approach for controlling bleeding, but it should be done after ensuring adequate precautions are in place to prevent cross-contamination.
C: Sit the client upright. While sitting upright can help reduce blood flow to the nose, it doesn't address the critical need for safety measures when dealing with potential pathogens.
D: Loosely pack the nose with gauze. This intervention may provide temporary relief, yet it is vital to first establish a safe environment through Standard Precautions before undertaking any invasive measures.
Question 8
Regular
A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first?
Correct!
Incorrect
The correct answer is: A
Rationale
Ask the client to gargle with mouthwash containing lidocaine.
This option addresses the client’s immediate discomfort by providing a soothing agent that can alleviate pain in the throat, facilitating better communication and comfort for the client during recovery from therapy.
B: Administer prescribed intravenous pain medications. Prioritizing medication administration without first assessing the underlying cause may overlook the potential for simpler, less invasive interventions to relieve the client's symptoms.
C: Explain that soreness is normal and will improve in a couple days. While education is essential, it does not provide immediate relief or address the client’s current discomfort effectively.
D: Assess the client's neck for redness and swelling. Although assessment is important, it does not provide immediate pain relief or address the client’s complaint of sore throat, delaying necessary care.
Correct Answer: A
Rationale: Ask the client to gargle with mouthwash containing lidocaine.
This option addresses the client’s immediate discomfort by providing a soothing agent that can alleviate pain in the throat, facilitating better communication and comfort for the client during recovery from therapy.
B: Administer prescribed intravenous pain medications. Prioritizing medication administration without first assessing the underlying cause may overlook the potential for simpler, less invasive interventions to relieve the client's symptoms.
C: Explain that soreness is normal and will improve in a couple days. While education is essential, it does not provide immediate relief or address the client’s current discomfort effectively.
D: Assess the client's neck for redness and swelling. Although assessment is important, it does not provide immediate pain relief or address the client’s complaint of sore throat, delaying necessary care.
Question 9
Regular
A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond?
Correct!
Incorrect
The correct answer is: B
Rationale
B: This is normal after surgery. What types of food do you like to eat?
The client’s perception of taste can be altered following a partial laryngectomy. Acknowledging this common experience while inviting discussion about preferred foods can help address their concerns and enhance their comfort during recovery.
A: Check if the client is swallowing properly.
Focusing solely on swallowing may overlook the client's expressed concern about taste, which is a significant aspect of their eating experience post-surgery and requires attentive consideration.
C: I will ask the dietitian to change the consistency of the food in your diet.
Changing food consistency addresses texture rather than taste, failing to engage with the client's specific issue of blandness and potentially overlooking their dietary preferences and enjoyment.
D: Notify the provider about potential nerve damage.
Assuming nerve damage without further assessment may lead to unnecessary alarm. The client's taste changes are typical after this surgery, and immediate notification of a provider may not be warranted.
Correct Answer: B
Rationale: B: This is normal after surgery. What types of food do you like to eat?
The client’s perception of taste can be altered following a partial laryngectomy. Acknowledging this common experience while inviting discussion about preferred foods can help address their concerns and enhance their comfort during recovery.
A: Check if the client is swallowing properly.
Focusing solely on swallowing may overlook the client's expressed concern about taste, which is a significant aspect of their eating experience post-surgery and requires attentive consideration.
C: I will ask the dietitian to change the consistency of the food in your diet.
Changing food consistency addresses texture rather than taste, failing to engage with the client's specific issue of blandness and potentially overlooking their dietary preferences and enjoyment.
D: Notify the provider about potential nerve damage.
Assuming nerve damage without further assessment may lead to unnecessary alarm. The client's taste changes are typical after this surgery, and immediate notification of a provider may not be warranted.
Question 10
Regular
A nurse cares for a client with facial and neck tissue edema after facial trauma. Which action should the nurse take first?
Correct!
Incorrect
The correct answer is: A
Rationale
Contact the provider and prepare for intubation.
In cases of facial trauma with tissue edema, airway compromise is a critical concern. Prioritizing intubation ensures that the airway is secured promptly, preventing respiratory distress and potential life-threatening situations due to swelling.
B: Administer prescribed albuterol nebulizer therapy. This action addresses bronchospasm rather than the immediate airway obstruction posed by facial edema, which is the priority in this scenario.
C: Place the client in high-Fowler's position. While this position can aid breathing in some situations, it does not address the urgent need to secure the airway compromised by edema.
D: Ask the client to perform deep-breathing exercises. Encouraging deep-breathing exercises is not appropriate when airway patency is at risk; securing the airway takes precedence over respiratory exercises.
Correct Answer: A
Rationale: Contact the provider and prepare for intubation.
In cases of facial trauma with tissue edema, airway compromise is a critical concern. Prioritizing intubation ensures that the airway is secured promptly, preventing respiratory distress and potential life-threatening situations due to swelling.
B: Administer prescribed albuterol nebulizer therapy. This action addresses bronchospasm rather than the immediate airway obstruction posed by facial edema, which is the priority in this scenario.
C: Place the client in high-Fowler's position. While this position can aid breathing in some situations, it does not address the urgent need to secure the airway compromised by edema.
D: Ask the client to perform deep-breathing exercises. Encouraging deep-breathing exercises is not appropriate when airway patency is at risk; securing the airway takes precedence over respiratory exercises.
Question 11
Regular
A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, 'How will this medication help me?' How should the nurse respond?
Correct!
Incorrect
The correct answer is: C
Rationale
This medication will treat your daytime restlessness.
Modafinil is a wakefulness-promoting agent specifically indicated for individuals experiencing excessive daytime sleepiness, such as those with sleep apnea. It does not directly address the apnea but alleviates its symptoms by enhancing alertness during waking hours.
A: This medication will treat your sleep apnea. Modafinil does not directly address the underlying condition of sleep apnea; it primarily manages symptoms associated with daytime sleepiness.
B: This sedative will help you to sleep at night. Modafinil is not a sedative; it promotes wakefulness and is not intended to facilitate nighttime sleep.
D: This analgesic will increase comfort while you sleep. Modafinil is not an analgesic and does not provide pain relief or comfort during sleep; its purpose is to enhance wakefulness.
Correct Answer: C
Rationale: This medication will treat your daytime restlessness.
Modafinil is a wakefulness-promoting agent specifically indicated for individuals experiencing excessive daytime sleepiness, such as those with sleep apnea. It does not directly address the apnea but alleviates its symptoms by enhancing alertness during waking hours.
A: This medication will treat your sleep apnea. Modafinil does not directly address the underlying condition of sleep apnea; it primarily manages symptoms associated with daytime sleepiness.
B: This sedative will help you to sleep at night. Modafinil is not a sedative; it promotes wakefulness and is not intended to facilitate nighttime sleep.
D: This analgesic will increase comfort while you sleep. Modafinil is not an analgesic and does not provide pain relief or comfort during sleep; its purpose is to enhance wakefulness.
Question 12
Regular
A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first?
Correct!
Incorrect
The correct answer is: D
Rationale
D: Make sure the string is taped to the client's cheek. Ensuring the string is securely taped is crucial for safely managing posterior nasal packing, preventing accidental removal and maintaining effective hemostasis during the healing process.
A: Assess the client's pain level. While monitoring pain is important, securing the packing takes precedence to prevent complications associated with dislodgment or bleeding.
B: Check the client's oxygen saturation. Although oxygen saturation is vital for overall health, ensuring the packing is secure directly addresses the immediate risk of further bleeding.
C: Teach the client about the causes of nasal bleeding. Education is beneficial but does not address the urgent need for proper management of the packing, which is essential for stabilization.
Correct Answer: D
Rationale: D: Make sure the string is taped to the client's cheek. Ensuring the string is securely taped is crucial for safely managing posterior nasal packing, preventing accidental removal and maintaining effective hemostasis during the healing process.
A: Assess the client's pain level. While monitoring pain is important, securing the packing takes precedence to prevent complications associated with dislodgment or bleeding.
B: Check the client's oxygen saturation. Although oxygen saturation is vital for overall health, ensuring the packing is secure directly addresses the immediate risk of further bleeding.
C: Teach the client about the causes of nasal bleeding. Education is beneficial but does not address the urgent need for proper management of the packing, which is essential for stabilization.
Question 13
Regular
A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this client's teaching?
Correct!
Incorrect
The correct answer is: B
Rationale
Using a humidifier requires strict cleanliness to prevent potential infections, especially after a laryngectomy. The nurse should emphasize the importance of regular cleaning to maintain a safe environment for airway healing.
A: Add peppermint oil to the humidifier to relax the airway. Essential oils can irritate the airway post-laryngectomy, leading to adverse reactions rather than providing relief.
C: Keep the humidifier filled with water at all times. Stagnant water can promote bacterial growth, posing a health risk rather than ensuring consistent humidity levels.
D: Use the humidifier when you sleep, even during daytime naps. While beneficial during sleep, continuous use without breaks can lead to excessive moisture, potentially causing respiratory issues.
Correct Answer: B
Rationale: Using a humidifier requires strict cleanliness to prevent potential infections, especially after a laryngectomy. The nurse should emphasize the importance of regular cleaning to maintain a safe environment for airway healing.
A: Add peppermint oil to the humidifier to relax the airway. Essential oils can irritate the airway post-laryngectomy, leading to adverse reactions rather than providing relief.
C: Keep the humidifier filled with water at all times. Stagnant water can promote bacterial growth, posing a health risk rather than ensuring consistent humidity levels.
D: Use the humidifier when you sleep, even during daytime naps. While beneficial during sleep, continuous use without breaks can lead to excessive moisture, potentially causing respiratory issues.
Question 14
Multiple Choice
A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.)
Correct!
Incorrect
The correct answer is: A,B,C,D
Rationale
Observe for clear drainage, assess for signs of bleeding, perform a neurologic examination, and monitor vital signs are essential actions for a nurse caring for a client post-surgery for a nasal fracture. Each step ensures proper recovery and identifies potential complications early.
A: Observe for clear drainage. This action is vital to detect cerebrospinal fluid leaks, which can indicate a serious complication following nasal surgery.
B: Assess for signs of bleeding. Monitoring for bleeding is crucial as it ensures timely intervention if the client experiences excessive blood loss post-surgery.
C: Perform a neurologic examination. Conducting a neurologic assessment is important to identify any potential head injury or complications arising from anesthesia or the surgical procedure.
D: Monitor vital signs. Keeping track of vital signs is essential for detecting any changes in the client's condition that may require immediate medical attention.
Correct Answer: A,B,C,D
Rationale: Observe for clear drainage, assess for signs of bleeding, perform a neurologic examination, and monitor vital signs are essential actions for a nurse caring for a client post-surgery for a nasal fracture. Each step ensures proper recovery and identifies potential complications early.
A: Observe for clear drainage. This action is vital to detect cerebrospinal fluid leaks, which can indicate a serious complication following nasal surgery.
B: Assess for signs of bleeding. Monitoring for bleeding is crucial as it ensures timely intervention if the client experiences excessive blood loss post-surgery.
C: Perform a neurologic examination. Conducting a neurologic assessment is important to identify any potential head injury or complications arising from anesthesia or the surgical procedure.
D: Monitor vital signs. Keeping track of vital signs is essential for detecting any changes in the client's condition that may require immediate medical attention.
Question 15
Multiple Choice
A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.)
Correct!
Incorrect
The correct answer is: B,E
Rationale
B: A 65-year-old who had a biopsy 2 days ago.
This client is stable with a straightforward postoperative recovery, making them suitable for LPN care. The LPN can effectively monitor vital signs and manage routine care needs.
E: An 80-year-old with esophageal cancer who is awaiting gastric tube placement.
This patient requires pre-procedural care and monitoring, which is within the LPN's scope, allowing them to assist effectively under RN supervision.
A: A 32-year-old who had a radical neck dissection 6 hours ago.
This client is in the early postoperative phase and needs close monitoring and assessment, which requires the expertise of an RN for complications.
C: A 55-year-old who needs discharge teaching after a laryngectomy.
Discharge teaching involves complex education and assessment, necessitating an RN’s expertise to ensure comprehensive understanding and address potential complications effectively.
D: A 67-year-old who is awaiting preoperative teaching for laryngeal cancer.
Preoperative teaching requires in-depth knowledge and assessment skills that are beyond an LPN's scope, thus necessitating an RN's involvement for appropriate patient education.
Correct Answer: B,E
Rationale: B: A 65-year-old who had a biopsy 2 days ago.
This client is stable with a straightforward postoperative recovery, making them suitable for LPN care. The LPN can effectively monitor vital signs and manage routine care needs.
E: An 80-year-old with esophageal cancer who is awaiting gastric tube placement.
This patient requires pre-procedural care and monitoring, which is within the LPN's scope, allowing them to assist effectively under RN supervision.
A: A 32-year-old who had a radical neck dissection 6 hours ago.
This client is in the early postoperative phase and needs close monitoring and assessment, which requires the expertise of an RN for complications.
C: A 55-year-old who needs discharge teaching after a laryngectomy.
Discharge teaching involves complex education and assessment, necessitating an RN’s expertise to ensure comprehensive understanding and address potential complications effectively.
D: A 67-year-old who is awaiting preoperative teaching for laryngeal cancer.
Preoperative teaching requires in-depth knowledge and assessment skills that are beyond an LPN's scope, thus necessitating an RN's involvement for appropriate patient education.
Question 16
Multiple Choice
A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture.
Correct!
Incorrect
The correct answer is: A,B,C,D
Rationale
You will need to cut the wires if you start vomiting. This instruction is critical for ensuring the patient's airway remains clear and preventing choking, as the fixed centric occlusion restricts mouth movement and could lead to complications during vomiting.
E: Gargle with mouthwash that contains Benadryl once a day. This recommendation lacks relevance as Benadryl is an antihistamine, not typically indicated for oral hygiene or infection prevention in this context.
C: Irrigate your mouth every 2 hours to prevent infection. Frequent irrigation may disrupt the healing process and is not typically recommended for patients with fixed occlusion, which requires careful oral care.
D: Sleep in a semi-Fowler's position after the surgery. While this position can be beneficial for some conditions, it does not specifically address the needs of a patient with a mandibular fracture under occlusion.
B: Eat soft or liquid meals each day while recovering. Although a soft diet is advisable, it does not relate to the immediate concern of managing potential choking during vomiting episodes.
Correct Answer: A,B,C,D
Rationale: You will need to cut the wires if you start vomiting. This instruction is critical for ensuring the patient's airway remains clear and preventing choking, as the fixed centric occlusion restricts mouth movement and could lead to complications during vomiting.
E: Gargle with mouthwash that contains Benadryl once a day. This recommendation lacks relevance as Benadryl is an antihistamine, not typically indicated for oral hygiene or infection prevention in this context.
C: Irrigate your mouth every 2 hours to prevent infection. Frequent irrigation may disrupt the healing process and is not typically recommended for patients with fixed occlusion, which requires careful oral care.
D: Sleep in a semi-Fowler's position after the surgery. While this position can be beneficial for some conditions, it does not specifically address the needs of a patient with a mandibular fracture under occlusion.
B: Eat soft or liquid meals each day while recovering. Although a soft diet is advisable, it does not relate to the immediate concern of managing potential choking during vomiting episodes.
Question 17
Multiple Choice
A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretion? (Select all that apply.)
Correct!
Incorrect
The correct answer is: A,C,D,E
Rationale
Clients A, C, D, and E are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions due to their neurological impairments or conditions affecting swallowing and airway management.
B: A 36-year-old who fractured his left femur. This client’s injury does not inherently impair respiratory function or swallowing, making asphyxiation risk lower compared to the others.
Correct Answer: A,C,D,E
Rationale: Clients A, C, D, and E are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions due to their neurological impairments or conditions affecting swallowing and airway management.
B: A 36-year-old who fractured his left femur. This client’s injury does not inherently impair respiratory function or swallowing, making asphyxiation risk lower compared to the others.
Quiz Complete!
Care of Patients with Noninfectious Upper Respiratory Problems
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