ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 29 Questions
Question 1 of 5
A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?
Correct Answer: D
Rationale: A patent airway is the priority. The nurse first should make sure that the airway is patent and then should determine whether the client is in pain and whether bone displacement or blood loss has occurred.
Question 2 of 5
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?
Correct Answer: A
Rationale: The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF, as a CSF leak places the client at risk for infection.
Question 3 of 5
A nurse assesses a client who reports waking up, feeling very tired, even after 4 hours of good sleep. Which action should the nurse take first?
Correct Answer: A
Rationale: The client's symptoms suggest possible sleep apnea, which can cause fatigue despite adequate sleep duration. Assessing for sleep apnea is the priority to identify the underlying cause and guide further management.
Question 4 of 5
The client with vocal cord polypusis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration.
Correct Answer: B
Rationale: Tucking the chin down during swallowing helps prevent aspiration by closing off the airway. Tilting the head back would increase the chance of aspiration. Breathing slowly or keeping the head still does not specifically reduce aspiration risk.
Question 5 of 5
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstruction?
Correct Answer: C
Rationale: The client who is extremely overweight is at the highest risk for airway obstruction due to the increased likelihood of conditions like sleep apnea, which can cause airway obstruction during sleep.