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
Question 2A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first?
a. A 66-year-old client with a barrel chest and clubbed fingernails
b. A 48-year-old client with an oxygen saturation level of 92 at rest
c. A 35-year-old client who has a longer expiratory phase than inspiratory phase
d. A 27-year-old client with a heart rate of 120 beats/min
Question 3A 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
Question 4A 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 client's 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-Fowler's position after the surgery.
e. Gargle with mouthwash that contains Benadryl once a day.
Question 5A 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
f.
Swollen chin
Question 6A 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.
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