Chapter 29

After teaching a client who is prescribed voice rest therapy for vocal cord polyps, a nurse assesses the clients understanding. Which statement indicates the client needs further teaching?

" When I speak, I will whisper rather than use a normal tone of voice "a

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this clients teaching?

"Make sure you clean the humidifier to prevent infection."

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?

"This medication will promote daytime wakefulness."

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions. Select all that apply

24 year old with traumatic brain injury 58 year old with risk of aspiration after radiation therapy 66 year old quadriplegic with a sacral ulcer 80 year old who is aphasic after a cerebral vascular accident.

A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a LPN?

A 43 year old diagnosed with cancer 2 days ago. An 88 year old with esophageal cancer who is awaiting gastric tube placement.

A nurse assesses clients on the medical-surgery unit. Which client is at greatest risk for developing sleep apnea?

A 55 year old woman who is 50 lbs overweight.

A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?

Airway patency

A nurse assesses a client who reports waking up very tired, even after 8 hours of good sleep. Which action should the nurse take first?

Ask the client if he has been evaluated for sleep apnea.

A nurse cares for a patient after radiation for lung cancer. The client reports a sore throat. Which action should the nurse take first?

Ask the client to gargle with mouthwash containing lidocaine.

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery?

Assist the client to choose a communication method.

A nurse assessed a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and trouble with vision. Which action should the nurse take next?

Collect the nasal drainage on a piece of filter paper.

While assessing a patient who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?

Contact the provider and prepare for intubation.

A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in the clients teaching? Select all that apply.

Cut wires if you start vomiting. Eat 6 soft or liquid meals each day Irrigate you're mouth every 2 hours to prevent infection. Sleep in a semi-Fowler's position after surgery.

A nurse assesses a client who has developed epistaxis. Which condition in the clients history should the nurse identify as a potential contributor for this problem? Select all that apply.

Hypertension Leukemia Cocaine use

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first?

Initiate standard precautions.

A nurse is caring for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first?

Make sure the string is attached to the clients cheek.

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.

Observe for clear drainage Assess for signs of bleeding Watch the client for frequent swallowing Ask the client to open his or her mouth

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? Select all that apply

Strider ecchymosis behind the ear

A nurse cares for a client who had a partial laryngectomy 10 days ago. The clients states all food tastes bland. How should the nurse respond?

This is normal after surgery. Which type of foods do you like?

A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach to avoid aspiration?

Tuck the chin down when swallowing.