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 B
Explanation
Choice A reason: Consuming a high-protein diet is not typically recommended for clients with hepatitis B. While protein is essential for overall health, excessive protein intake can put additional strain on the liver. Instead, a balanced diet with adequate carbohydrates, fruits, and vegetables is advised to support liver function.
Choice B reason: Resting frequently throughout the day is crucial for clients with hepatitis B. The liver is responsible for many vital functions, including detoxification, protein synthesis, and the production of biochemicals necessary for digestion. When the liver is inflamed or damaged, as in hepatitis B, it needs ample rest to recover and function properly.
Choice C reason: Clients with hepatitis B should not donate blood. Hepatitis B is a bloodborne virus, and donating blood can transmit the infection to others. Blood donation guidelines strictly prohibit individuals with hepatitis B from donating blood, regardless of the time elapsed since completing medication.
Choice D reason: Taking acetaminophen every 4 hours for discomfort is not advisable for clients with hepatitis B. Acetaminophen is metabolized by the liver, and excessive use can lead to liver damage. Clients with liver conditions should use acetaminophen sparingly and under medical supervision to avoid exacerbating liver damage.
Correct Answer is A
Explanation
Choice A: He is NPO until the speech-language pathologist performs a swallowing evaluation.
This is the most appropriate response. NPO stands for “nil per os,” which means nothing by mouth. After a stroke, it is crucial to assess the patient’s ability to swallow safely to prevent aspiration, which can lead to pneumonia and other complications. A speech-language pathologist is trained to evaluate swallowing function and determine the safest diet for the patient. Until this evaluation is completed, the patient should not consume any food or liquids.
Choice B: Be sure to sit him up when you are feeding him to make him feel more natural.
While sitting the patient up during feeding is important to reduce the risk of aspiration, it is not sufficient on its own. Without a proper swallowing evaluation, feeding the patient could still pose significant risks. Therefore, this choice is not the most appropriate response.
Choice C: You may give him a full-liquid diet, but please avoid solid foods until he gets stronger.
A full-liquid diet might seem like a safer option, but without a swallowing evaluation, there is still a risk of aspiration. The patient’s ability to handle even liquids needs to be assessed by a professional before any oral intake is allowed.
Choice D: Just be sure to add some thickener in his liquids to prevent choking and aspiration.
Thickening liquids can help manage dysphagia, but this should only be done after a swallowing evaluation has determined the appropriate consistency. Administering thickened liquids without an evaluation could still result in aspiration if the patient has severe swallowing difficulties.
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