The neurologic assessment of a patient indicates impaired function of the glossopharyngeal (CN IX) and the vagus nerve (CN X). Based on these findings the nurse plans to:

Insert an oral airway and suction as necessary.

Withhold oral fluids or foods.

Speak clearly while facing the client.

Apply artificial tears to protect the cornea.

Answer and Explanation

The Correct Answer is B

A. Inserting an oral airway and suctioning may be indicated for airway management, but the primary concern is the impaired function of the glossopharyngeal and vagus nerves, which affects swallowing and the risk of aspiration.
B. Withholding oral fluids or foods is crucial because impaired function of these cranial nerves increases the risk of aspiration and can lead to choking or pneumonia, making this the priority action.
C. Speaking clearly while facing the client is a good communication practice but does not address the immediate concern of impaired swallowing and risk of aspiration.
D. Applying artificial tears is important for protecting the cornea, but it is not directly related to the functions of CN IX and CN X or the immediate management of swallowing difficulties.

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Correct Answer is C

Explanation

A. The absence of bowel sounds shortly after surgery is a common finding and does not necessarily indicate a complication at this time; it is expected during the initial postoperative period.
B. An SPO2 of 90% while the client is asleep is concerning, but it does not take precedence over signs of possible surgical complications that could require immediate intervention.
C. Increasing abdominal distention is a critical sign that could indicate serious complications such as an anastomotic leak, bowel obstruction, or intra-abdominal bleeding, and it requires immediate notification of the surgeon for further evaluation and potential intervention.
D. A small amount of green-tinged fluid from the nasogastric tube is typical postoperatively and does not necessitate immediate notification to the surgeon unless the volume is excessive or other concerning signs are present.

A. pick up the implant with gloved hands and place it in bedside container. B. pick up the implant with long handled forceps and place it in a lead container. C. call for the rapid response team. D. call the radiation oncologist immediately.

Correct Answer is B

Explanation

A. Picking up the implant with gloved hands does not ensure safety and proper handling of a radioactive material, as gloves do not provide adequate protection against radiation exposure.
B. Using long-handled forceps to pick up the implant and placing it in a lead container is the correct action, as it minimizes radiation exposure to the nurse and ensures the safe containment of the radioactive source.
C. Calling for the rapid response team is unnecessary in this scenario; the situation requires immediate containment of the radioactive material rather than emergency medical intervention.
D. Calling the radiation oncologist is not the first action; while it is important to inform the physician afterward, the priority is to secure the radioactive implant properly to prevent exposure.

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The neurologic assessment of a patient indicates impaired function of the glossopharyngeal (CN IX) and the vagus nerve (CN X). Based on these findings the nurse plans to:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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