chapter 29 Med surg
The emergency nurse is preparing to care for a client sustaining facial and neck injuries in a motor vehicle crash. Which of these is the priority at this time?
Ensure a tracheostomy tray is at the bedside
The standard perioperative laryngectomy plan of care includes these interventions. Which intervention will be most important for the nurse to accomplish preoperatively?
Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board.
A client has received packing for a posterior nosebleed. In reviewing the client's prescriptions, which of these does the nurse question?
"Ibuprofen 800 mg every 8 hours as needed for pain."
The nurse is caring for a client who has just had radical neck surgery and is receiving mechanical ventilation. Which of these assessments takes priority
Observing the dressing for bright-red blood
The nurse is supervising a client during mealtime who has had a recent laryngectomy. Which of these is essential to include in the plan of care?
Swallow twice to clear the airway
The nurse in the radiation therapy department is teaching the client about use of fluoride gel trays during radiation treatments. How will the nurse explain the purpose of wearing fluoride gel trays during radiation therapy of the mouth?
They prevent radiation scatter from metal in the mouth.
The nurse manager at a long-term-care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks is appropriate to delegate to a nursing assistant?
Washing the skin with plain soap and water
When reviewing discharge care with the client who has had a laryngectomy, the client states the morphine doesn't work well because he still has shooting pain in the incisional area. Which of these does the nurse suggest be prescribed?
nsaids
A client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response?
"Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe."
Which statement by a client with a laryngectomy indicates a need for further discharge teaching?
"I can't put anything over my stoma to cover it."
A client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure?
"I will have to take special care not to aspirate while eating."
A client's mother asks what is the most important thing she will need to know to care for her son, who is having an inner maxillary fixation for a mandibular fracture. Which of these does the nurse communicate as the priority?
"Make sure he always carries the wire cutters with him."
A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which preoperative intervention can be accomplished by an LPN/LVN working on the unit?
Administering preoperative antibiotics and anxiolytics
The community health nurse is providing education about risk factors for head and neck cancer? Which of these risks will be included in the teaching session?
Alcohol and smokeless tobacco use
A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first?
Ask the client whether the mask fits tightly over the mouth and nose.
The nurse assesses that the flap created after laryngectomy in the immediate post-operative period appears dusky in color. What is the nurse's first action?
Assess flow to the area using a Doppler device.
The charge nurse in the emergency department (ED) is making assignments for the team including a new RN who has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse?
Client on warfarin (Coumadin) with epistaxis with brisk bleeding
The nurse enters the room while the client is eating breakfast and recognizes that the client has an upper airway obstruction with signs of hypoxemia. What is the nurse's first action?
Perform the abdominal thrust maneuver.
The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse?
Excessive swallowing
The nurse is caring for the client who has had an open reduction and internal fixation (ORIF) with titanium plates to repair a LeFort III fracture. Which of these activities will the nurse include in the teaching plan?
It is important to have good oral hygiene using an irrigating device such as Waterpik.
The nurse is planning care for the non-English-speaking client who is on complete voice rest after head and neck surgery. The nurse must verify the client's allergies prior to medication administration. What alternative method of communication is best for the nurse to use?
Translation phone service
which client does the nurse expect complications of sleep apnea? a. 28 y/o overweight with a short neck b. 48 y/o with diabetes c. 78 y/o with dentures
a
The nurse is caring for a client with facial trauma who has recently developed restlessness. Which of these is the nurse's first priority?
apply oxygen
a client will undergo radiation for head and neck cancer asks what effects are expected? a. scalp alopecia b. tase loss/sensation loss c. increased risk for infection d. increased risk of skin breakdown e. increased risk for cavaties
b d e
what intervention is most appropriate for the nurse to teach a client with nasal fracture to reduce bleeding? a. avoid blowing the nose b. drink a lot of fluid c. take antibiotics d. use acetaminophen instead of NSAID
d a
The nurse is caring for a client with laryngeal trauma. Which sign/symptom does the nurse determine is most critical to report to the provider?
stridor
