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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason: Monitoring the heart rate is crucial when administering amiodarone, as this drug can cause bradycardia (a slower than normal heart rate). Amiodarone affects the electrical conduction system of the heart, and close monitoring helps ensure that the heart rate remains within a safe range. The normal resting heart rate for adults is typically between 60 and 100 beats per minute.

Choice B reason: Respiratory rate monitoring is essential because amiodarone can cause pulmonary toxicity, which may manifest as interstitial pneumonitis or pulmonary fibrosis. Early detection of respiratory changes can help prevent severe complications. The normal respiratory rate for adults is 12 to 20 breaths per minute.

Choice C reason: Monitoring heart rhythm is necessary because amiodarone is used to treat arrhythmias, and it can also cause new arrhythmias or exacerbate existing ones. Continuous ECG monitoring helps detect any abnormal rhythms early, allowing for prompt intervention. Normal sinus rhythm is characterized by a regular rhythm with a rate of 60 to 100 beats per minute.

Choice D reason: Cardiac output monitoring is important because amiodarone can affect the contractility of the heart and overall cardiac function. Cardiac output is a measure of the amount of blood the heart pumps in one minute, and it is crucial for ensuring adequate tissue perfusion. Normal cardiac output ranges from 4 to 8 liters per minute in adults.

A. Stretch marks B. Foul-smelling breath C. Increased abdominal girth D. Visible distended veins E. Rapid weight gain

Correct Answer is ["C","D","E"]

Explanation

Choice A reason: Stretch marks, also known as striae, are not specific to ascites. They can occur due to rapid weight gain or loss, pregnancy, or other conditions that cause the skin to stretch. While they may be present in individuals with ascites due to rapid abdominal expansion, they are not a primary clinical manifestation of ascites.

Choice B reason: Foul-smelling breath, or halitosis, is not a typical symptom of ascites. It can be associated with various conditions, including poor oral hygiene, gastrointestinal disorders, or liver disease, but it is not a direct indicator of ascites.

Choice C reason: Increased abdominal girth is a primary clinical manifestation of ascites. Ascites is characterized by the accumulation of fluid in the peritoneal cavity, leading to noticeable abdominal distension. This symptom is often accompanied by a feeling of fullness or bloating.

Choice D reason: Visible distended veins, particularly around the abdomen, can be a sign of ascites. This occurs due to increased pressure in the abdominal veins as a result of fluid accumulation. The veins become more prominent and visible under the skin.

Choice E reason: Rapid weight gain is another key indicator of ascites. The accumulation of fluid in the abdomen leads to a significant increase in body weight over a short period. This rapid weight gain is often one of the first signs that prompts further investigation for ascites.

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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)

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