Which of the following actions would the nurse take when caring for a client with nasal packing who had surgery 6 hours ago? (Select all that apply)
Observe for clear drainage.
Assess for signs of bleeding.
Watch the client for frequent swallowing.
Change the nasal packing.
Administer a nasal steroid to decrease edema.
Correct Answer : A,B,C
Choice A: Observe for clear drainage.
Reason: Observing for clear drainage is important as it can indicate cerebrospinal fluid (CSF) leakage, especially after nasal or sinus surgery. CSF leakage is a serious complication that requires immediate medical attention. Clear drainage from the nose should be tested for the presence of glucose, which can confirm if it is CSF.
Choice B: Assess for signs of bleeding.
Reason: Assessing for signs of bleeding is crucial in the immediate postoperative period. Nasal packing can sometimes mask ongoing bleeding, so it is important to monitor for any signs of excessive blood loss. This includes checking for blood-soaked dressings, frequent swallowing (which can indicate blood trickling down the throat), and changes in vital signs such as increased heart rate and decreased blood pressure.
Choice C: Watch the client for frequent swallowing.
Reason: Watching the client for frequent swallowing is important because it can be a sign of posterior nasal bleeding. Blood can trickle down the back of the throat, causing the client to swallow frequently. This is a subtle but significant sign that should prompt further investigation and possible intervention.
Choice D: Change the nasal packing.
Reason: This choice is incorrect. Nasal packing should not be changed by the nurse without specific orders from the physician. Changing the packing prematurely can disrupt the surgical site, cause bleeding, and increase the risk of infection. The packing is usually removed by the surgeon or under their direct supervision.
Choice E: Administer a nasal steroid to decrease edema.
Reason: Administering a nasal steroid can help reduce inflammation and edema in the nasal passages. However, this should only be done if prescribed by the physician. Nasal steroids can help improve breathing and reduce discomfort, but they must be used according to medical guidance to avoid potential side effects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Increased serum amylase is a key indicator of acute pancreatitis. Amylase is an enzyme produced by the pancreas to help digest carbohydrates. In cases of acute pancreatitis, the pancreas becomes inflamed, leading to the release of amylase into the bloodstream. Elevated levels of serum amylase, typically more than three times the upper limit of normal, are a strong indication of acute pancreatitis. This enzyme level usually rises within a few hours of the onset of pancreatitis and can remain elevated for several days.
Choice B Reason:
Increased serum calcium is not typically associated with acute pancreatitis. In fact, acute pancreatitis can often lead to hypocalcemia (low calcium levels) due to fat saponification in the pancreas, where calcium binds with fatty acids. Therefore, an increase in serum calcium would not be expected in a patient with acute pancreatitis. Monitoring calcium levels is important, but an increase is not a diagnostic marker for this condition.
Choice C Reason:
Decreased WBC (white blood cell count) is not a characteristic finding in acute pancreatitis. On the contrary, acute pancreatitis often leads to an elevated WBC count due to the inflammatory response in the body. Leukocytosis (increased WBC) is a common finding in many inflammatory and infectious conditions, including acute pancreatitis. Therefore, a decreased WBC count would not be expected and does not support the diagnosis of acute pancreatitis.
Choice D Reason:
Decreased serum lipase is incorrect. Similar to amylase, lipase is another enzyme produced by the pancreas, which helps in the digestion of fats. In acute pancreatitis, serum lipase levels also increase significantly, often more than three times the upper limit of normal. Lipase levels tend to rise slightly later than amylase but remain elevated for a longer period, making it a useful marker for diagnosing acute pancreatitis. Therefore, decreased serum lipase would not be expected in this condition.
Correct Answer is D
Explanation
Choice A Reason:
Malfunction of the alarm button is unlikely to be the cause of increased peak airway pressure. The alarm is designed to alert the nurse to a problem with the ventilator or the patient’s airway, not to malfunction itself. Therefore, this is not the first thing the nurse should assess.
Choice B Reason:
A cut or slice in the tubing from the ventilator could cause a loss of pressure or air leak, but it would not typically result in increased peak airway pressure. Instead, it would likely cause a decrease in pressure and potentially trigger a different alarm.
Choice C Reason:
Higher than normal endotracheal cuff pressure can contribute to increased peak airway pressure. However, it is not the most immediate concern compared to a kink in the tubing, which can completely obstruct airflow and rapidly compromise the patient’s ventilation.
Choice D Reason:
A kink in the ventilator tubing is a common and immediate cause of increased peak airway pressure. It obstructs the flow of air, leading to a buildup of pressure in the system. This is the first thing the nurse should assess and correct to ensure the patient is receiving adequate ventilation.
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