MedSurg Ch. 29 NCLEX

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.) a. A 24-year-old with a traumatic brain injury b. A 36-year-old who fractured his left femur c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident

a. A 24-year-old with a traumatic brain injury c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident

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. A nonsteroidal anti-inflammatory drug b. Lorazepam c. An increase in the morphine dose d. Acetaminophen

a. A nonsteroidal 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? a. Administering preoperative antibiotics and anxiolytics b. Assessing the client's nutritional status and need for nutrition supplements c. Having the client sign the operative consent form d. Teaching the client about the need for tracheal suctioning after surgery

a. 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? a. Alcohol and smokeless tobacco use b. Chronic laryngitis and voice abuse c. Marijuana use and exposure to industrial chemicals d. Poor oral hygiene and smoking cigarettes

a. Alcohol and smokeless tobacco use

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? a. Ask the client to gargle with mouthwash containing lidocaine. b. Administer prescribed intravenous pain medications. c. Explain that soreness is normal and will improve in a couple days. d. Assess the clients neck for redness and swelling.

a. Ask the client to gargle with mouthwash containing lidocaine.

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? a. Ask the client whether the mask fits tightly over the mouth and nose. b. Discuss the use of autotitrating positive airway pressure (APAP). c. Plan to teach the client about treatment with modafinil (Provigil). d. Suggest that a nasal mask be used instead of a full facemask.

a. Ask the client whether the mask fits tightly over the mouth and nose.

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? a. Client on warfarin (Coumadin) with epistaxis with brisk bleeding b. Client with facial burns caused by a mattress fire while sleeping c. Client with possible facial fractures after a motor vehicle collision d. Client with suspected bilateral vocal cord paralysis and stridor

a. Client on warfarin (Coumadin) with epistaxis with brisk bleeding

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? a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck.

a. Collect the nasal drainage on a piece of filter paper.

11. While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? a. Contact the provider and prepare for intubation. b. Administer prescribed albuterol nebulizer therapy. c. Place the client in high-Fowlers position. d. Ask the client to perform deep-breathing exercises.

a. Contact the provider and prepare for intubation.

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? a. Ensure a tracheostomy tray is at the bedside b. Place pressure on areas of hemorrhage c. Assess the mastoid area for battle sign d. Administer isotonic fluid term-22replacement

a. Ensure a tracheostomy tray is at the bedside

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first? a. Initiate Standard Precautions. b. Apply direct pressure. c. Sit the client upright. d. Loosely pack the nares with gauze.

a. Initiate Standard Precautions.

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.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.

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

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? a. Observing the dressing for bright-red blood b. Monitoring for decreased level of consciousness c. Evaluating the outcome of pain management strategies d. Analyzing trends of urine output since surgery

a. Observing the dressing for bright-red blood

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain

a. Stridor d. Ecchymosis behind the ear

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? a. Swallow twice to clear the airway b. Thicken all foods to a honey consistency c. Elevate the head of the bed to 45 degrees d. Review the results of the radiographic swallowing study

a. Swallow twice to clear the airway

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 this clients teaching? (Select all that apply.) a. You will need to cut the wires if you start vomiting. b. Eat six soft or liquid meals each day while recovering. c. Irrigate your mouth every 2 hours to prevent infection. d. Sleep in a semi-Fowlers position after the surgery. e. Gargle with mouthwash that contains Benadryl once a day.

a. You will need to cut the wires if you start vomiting. b. Eat six soft or liquid meals each day while recovering. c. Irrigate your mouth every 2 hours to prevent infection. d. Sleep in a semi-Fowlers position after the surgery.

The standard perioperative laryngectomy plan of care includes these interventions. Which intervention will be most important for the nurse to accomplish preoperatively? a. Educate the client about ways to avoid aspiration when swallowing after the surgery. b. Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. c. Discuss appropriate clothing to wear that will help cover the laryngectomy stoma and decrease social isolation after surgery. d. Teach the client and significant others about how to suction and perform wound care of the stoma.

b. Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board.

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? a. Individuals with a titanium plate should not have an MRI and should carry a wallet card stating this. b. It is important to have good oral hygiene using an irrigating device such as Waterpik. c. Let the health care team know if you are experiencing any pain. d. We will be checking behind your ear for any bruising to assess for additional trauma.

b. It is important to have good oral hygiene using an irrigating device such as Waterpik.

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this clients teaching? a. Add peppermint oil to the humidifier to relax the airway. b. Make sure you clean the humidifier to prevent infection. c. Keep the humidifier filled with water at all times. d. Use the humidifier when you sleep, even during daytime naps.

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

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? a. Alphabet board b. Picture board c. Translation phone service d. Word board

b. Picture board

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? a. I will consult the speech therapist to ensure you are swallowing properly. b. This is normal after surgery. What types of food do you like to eat? c. I will ask the dietitian to change the consistency of the food in your diet. d. Replacement of protein, calories, and water is very important after surgery.

b. This is normal after surgery. What types of food do you like to eat?

A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Tuck the chin down when swallowing. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing.

b. Tuck the chin down when swallowing.

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? a. I will stay away from smokers to minimize inhalation of secondhand smoke. b. When I speak, I will whisper rather than use a normal tone of voice. c. For the next several weeks, I will not lift more than 10 pounds. d. I will drink at least three quarts of water each day to stay hydrated.

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

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant b. A 42-year-old man with gastroesophageal reflux disease c. A 55-year-old woman who is 50 pounds overweight d. A 73-year-old man with type 2 diabetes mellitus

c. A 55-year-old woman who is 50 pounds overweight

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery? a. Assess airway patency, breathing, and circulation. b. Administer prescribed intravenous pain medication. c. Assist the client to choose a communication method. d. Ambulate the client in the hallway to assess gait.

c. Assist the client to choose a communication method.

The nurse is caring for a client with facial trauma who has recently developed restlessness. Which of these is the nurse's first priority? a. Assess for bleeding on the drip moustache dressing. b. Provide ventilation with a manual resuscitation bag. c. Perform the abdominal thrust maneuver. d. Apply oxygen.

d. Apply oxygen.

A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first? a. Contact the provider for a prescription for sleep medication. b. Tell the client not to drink beverages with caffeine before bed. c. Educate the client to sleep upright in a reclining chair. d. Ask the client if he or she has ever been evaluated for sleep apnea.

d. Ask the client if he or she has ever been evaluated for sleep apnea.

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? a. Apply moist heat over the flap site. b. Massage the flap site vigorously. c. Place a tight dressing over the flap. d. Assess flow to the area using a Doppler device.

d. Assess flow to the area using a Doppler device.

A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first? a. Assess the clients pain level. b. Keep the clients head elevated. c. Teach the client about the causes of nasal bleeding. d. Make sure the string is taped to the clients cheek.

d. Make sure the string is taped to the clients cheek.

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? a. Attempt to remove the obstruction. b. Call the Rapid Response Team (RRT). c. Apply oxygen by non-rebreathing mask. d. Perform the abdominal thrust maneuver.

d. 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? a. Aphonia b. Hoarseness c. Loud snoring d. Stridor

d. Stridor

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? a. Administering throat-numbing lozenges b. Assessing the mouth for inflammation and infection c. Teaching about skin care while receiving radiation d. Washing the skin with plain soap and water

d. Washing the skin with plain soap and water

A client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure? a. "I hope I can learn esophageal speech." b. "I will have to take special care not to aspirate while eating." c. "I won't be able to breathe through my nose anymore." d. "It is hard to believe that I will never hear my own voice again."

b. "I will have to take special care not to aspirate while eating."

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.) a. A 32-year-old who had a radical neck dissection 6 hours ago b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago c. A 55-year-old who needs discharge teaching after a laryngectomy d. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement

b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement

A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets

b. Hypertension c. Leukemia d. Cocaine use

Which statement by a client with a laryngectomy indicates a need for further discharge teaching? a. "I must avoid swimming." b. "I can clean the stoma with soap and water." c. "I can project mucus when I laugh or cough." d. "I can't put anything over my stoma to cover it."

d. "I can't put anything over my stoma to cover it."

A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first? a. Facial pain b. Vital signs c. Bone displacement d. Airway patency

d. Airway patency

The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse? a. Ecchymosis b. Edema c. Excessive swallowing d. Sore throat

c. Excessive swallowing

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? a. "Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe." b. "Because your body isn't getting enough oxygen you wake up and breathe." c. "Your tongue may be blocking your throat, and you wake up because you are choking." d. "You really aren't waking up that often. It just feels that way."

a. "Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe."

A client has received packing for a posterior nosebleed. In reviewing the client's prescriptions, which of these does the nurse question? a. "Ibuprofen 800 mg every 8 hours as needed for pain." b. "Elevate the head of the bed 45 to 60 degrees." c. "Provide humidified air." d. "Have suction available at the bedside."

a. "Ibuprofen 800 mg every 8 hours as needed for pain."

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? a. They will keep the mouth moist during treatments. b. They prevent yellow teeth after treatment. c. They prevent radiation scatter from metal in the mouth. d. They will protect the taste buds on the tongue.

c. They prevent radiation scatter from metal in the mouth.

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? a. This medication will treat your sleep apnea. b. This sedative will help you to sleep at night. c. This medication will promote daytime wakefulness. d. This analgesic will increase comfort while you sleep.

c. This medication will promote daytime wakefulness.

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? a. "Make sure he gets enough calories each day." b. "He can only consume milk and ice cream until the wires come off." c. "He must brush his teeth every 2 hours." d. "Make sure he always carries the wire cutters with him."

d. "Make sure he always carries the wire cutters with him."