A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform first?

Correct Answer: D

Rationale: The correct answer is D: Airway patency. Ensuring airway patency is the top priority in any client assessment, especially in cases of facial trauma like a nasal fracture. This is because compromised airway can lead to respiratory distress or failure. Assessing airway patency should always be the first step to ensure the client's ability to breathe. Facial pain (A) may be important but does not address immediate life-threatening concerns. Vital signs (B) are important but assessing airway patency takes precedence for client safety. Bone displacement (C) is relevant but does not address the immediate need to maintain airway patency.

Correct Answer: D

Rationale: In assessing a client with trauma to the upper airway, the nurse should prioritize identifying the presence of laryngospasm. Laryngospasm is a serious complication that can occur due to upper airway trauma, leading to a sudden closure of the vocal cords and obstruction of the airway. This can result in severe respiratory distress and requires immediate intervention to prevent respiratory failure. Therefore, recognizing and addressing laryngospasm is crucial in the care of a client with upper airway trauma. Regarding the incorrect options: - Pain when talking (Option A) may be a symptom of upper respiratory infections or conditions like pharyngitis, but it is not specific to trauma of the upper airway. - Burning in the throat (Option B) is more indicative of acid reflux or irritation, not a primary symptom of upper airway trauma. - Increased nasal swelling (Option C) suggests nasal congestion or allergies rather than trauma to the upper airway. In an educational context, understanding the specific symptoms and complications of upper airway trauma is essential for nurses caring for patients with respiratory issues. By knowing the key signs to assess and intervene upon, nurses can provide timely and effective care to prevent further respiratory compromise in patients with upper airway trauma.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A: Assist client to sit up on the side of the bed. This intervention is appropriate to be delegated to a nursing assistant because it is a basic task that falls within their scope of practice and does not require specialized training or clinical judgment. Option B, instructing the client to cough effectively, involves providing specific guidance on a therapeutic technique that requires more knowledge and skill, making it more appropriate for a nurse to perform. Option C, teaching the client to use incentive spirometry, involves education on a medical device and its proper use, which is beyond the scope of a nursing assistant's role. Option D, auscultating breath sounds every 4 hours, is a skilled nursing assessment task that requires clinical judgment to interpret findings. This task should be performed by a nurse who can analyze the data collected and make appropriate decisions based on the assessment findings. In an educational context, understanding the delegation of tasks is crucial for healthcare professionals to work effectively as a team. By clearly delineating roles and responsibilities based on skill levels and scopes of practice, patient care can be delivered safely and efficiently. Nursing assistants play a vital role in supporting patient care by carrying out delegated tasks under the supervision of licensed nurses, ensuring that each team member contributes to the overall well-being of the patient.

Correct Answer: D

Rationale: The correct answer is D) Small airway closure earlier in expiration. As individuals age, changes occur in the respiratory system that can impact secretion clearance. Small airway closure earlier in expiration is a common age-related change that can hinder the effective clearance of secretions from the lungs. This closure can lead to air trapping and impaired gas exchange, making it harder to clear mucus and other secretions, thus increasing the risk of respiratory infections. Option A) Decreased functional cilia is not the correct answer because while cilia function may decline with age, it is not a primary factor contributing to decreased secretion clearance. Cilia play a role in moving mucus out of the airways, but their decline alone does not have as significant an impact as small airway closure. Option B) Decreased force of cough is not the correct answer because while cough strength may diminish with age, it is not the primary reason for decreased secretion clearance. Coughing is a mechanism to clear secretions, but small airway closure has a more direct impact on secretion clearance. Option C) Decreased chest wall compliance is not the correct answer because this factor primarily affects lung expansion and respiratory function but is not directly related to secretion clearance. While decreased chest wall compliance can impact overall lung function, it is not the primary reason for decreased secretion clearance in the respiratory system. Educationally, understanding age-related changes in the respiratory system is crucial for healthcare providers, especially those working with older adults. By recognizing these changes and their implications on respiratory function, providers can implement appropriate interventions to support effective secretion clearance and respiratory health in aging individuals.

Correct Answer: C

Rationale: The correct answer is C) Follow the written asthma action plan (e.g., take quick-relief medication) if the expiratory flow rate is in the yellow zone. This is the correct instruction because peak flow meters are used to monitor lung function in asthma patients. The yellow zone on the peak flow meter indicates caution, signaling that the patient's lung function is decreasing. By following the asthma action plan if the expiratory flow rate falls into the yellow zone, the patient can take appropriate steps to manage their asthma and prevent exacerbations. Option A is incorrect because carrying the flow meter at all times is not necessary and may lead to unnecessary anxiety for the patient. Option B is incorrect as checking the status of asthma every time quick-relief medication is taken may not be necessary and could lead to overuse of medication. Option D is incorrect as it describes the technique of using the flow meter, which is not the main focus of the question. Educationally, understanding how to use a peak flow meter and interpret the results is crucial for asthma management. Teaching patients how to monitor their lung function empowers them to take control of their condition and make informed decisions about their care. It also helps healthcare providers assess the effectiveness of treatment plans and adjust them accordingly.