Chapter 29: NCLEX

which interventions are most appropriate for the nurse to teach a client with a nasal fracture to reduce bleeding from the injury? - avoid blowing or picking the nose - drink at least 2000 mL of fluid daily - take the antibiotics for as long as they are prescribed - take in only liquids and eat no solid food for at least a week - change the drip dressing as soon as it becomes wet - use acetaminophen for pain rather than aspirin or other NSAIDs

- avoid blowing or picking the nose - use acetaminophen for pain rather than aspirin or other NSAIDs

with which client does the nurse anticipate complications form obstructive sleep apnea following abdominal surgery? - 48 y/o who has type 1 diabetes and chronic sinusitis - 78 y/o who wears upper and lower dentures - 28 y/o who is 80 lbs overweight and has a short neck

28 y/o who is 80 lbs overweight and has a short neck

Which statement by a client with a laryngectomy indicates a need for further discharge teaching?

I cant 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 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

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?

a non steroidal anti inflammatory drug

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

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 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 with epistaxis (nose bleed) with brisk bleeding

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 post op period, such as a magic slate or an alphabet board

The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse?

excessive swallowing

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 non steroidal anti-inflammatory drugs inhibit clotting

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

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 in the event of emesis

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 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 caring for a client with laryngeal trauma. Which sign/symptom does the nurse determine is most critical to report to the provider?

stridor

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

a client about to undergo radiation therapy for head and neck cancer asks what side effects are expected from this therapy. Which side effects does the nurse teach the client to expect - scale and eyebrows alopecia - taste sensation loss or changes - increased risk for sinus infections - increased risk for skin breakdown - moderate weight gain - increased risk for cavities

taste sensation loss or changes increased risk for skin breakdown increase risk for cavities

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 form metal in the mouth

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 picture board if a translation service is not readily available

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