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. Applying pressure to injection sites helps reduce bleeding but does not directly prevent tumor lysis syndrome.
B. Monitoring telemetry is important for patients with potential cardiac issues but is not specifically related to preventing complications from tumor lysis syndrome.
C. Ensuring a high fluid intake of 3000 to 5000 mL/day helps dilute electrolytes and reduce the risk of acute kidney injury and other complications associated with tumor lysis syndrome, making this the most crucial intervention.
D. Assisting the client in ambulatory activities may support their overall well-being but does not address the prevention of tumor lysis syndrome.

A. Administer a narcotic analgesic every two hours. B. Encourage a low-fat diet the first post-op day. C. Encourage the use of the incentive spirometer. D. Ambulate the client in the hall the first post-op evening.

Correct Answer is C

Explanation

A. While administering a narcotic analgesic may be necessary for pain management, it does not address the immediate post-operative needs related to respiratory function and mobility.
B. Encouraging a low-fat diet is important after a cholecystectomy, but this can be addressed after ensuring the client's respiratory function and mobilization are stable.
C. Encouraging the use of the incentive spirometer is the priority intervention as it promotes lung expansion, reduces the risk of atelectasis, and improves oxygenation, which is crucial in the post-operative period.
D. While ambulating the client is important for recovery and preventing complications such as deep vein thrombosis, it should follow ensuring that the patient is able to effectively use the incentive spirometer to maintain respiratory function first.

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Electrolyte	Normal Value Range
Serum sodium	135-145 mEq/L
Serum chloride	97-107 mEq/L
Serum potassium	3.5-5:3 mEq/L
Serum magnesium	1.6-2.2 mg/dL
Total serum calcium	8.2-10.2 mg/dL
lonized calcium	4.6-5.3 mg/dL
Serum phosphorus	2.5-4.5 mg/dL
Serum osmolality	275-295 mOsm/kg
Urine osmolality	250-900 mOsm/kg

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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention is most important for the nurse to implement to prevent complications from tumor lysis syndrome during chemotherapy?

Correct Answer is C

Explanation

The nurse is caring for a client post-operatively following an open (incisional) cholecystectomy. Which would be the priority nursing intervention for this client?

Correct Answer is C

Explanation

Which of the following interventions would the nurse emphasize during education to assist the patient diagnosed with trigeminal neuralgia in managing their pain?

The nurse is caring for a client diagnosed with cancer who is experiencing a decreased nutritional intake due to painful oral lesions. Which intervention would the nurse include in the plan of care?

The nurse is giving discharge instructions to a client newly diagnosed with lung cancer. The nurse understands the client requires additional discharge teaching when the client states:

The nurse is caring for a client in the immediate postoperative period following a pancreatoduodenectomy (Whipple) procedure. The nurse is assessing for decreased fluid volume in the client. What would the nurse assess first?

The nurse is caring for a client who is receiving external beam radiation for treatment of right upper lobe lung cancer. What problem should be anticipated following this treatment?

The nurse notes serosanguinous drainage from the nasogastric tube in the immediate postoperative period of a client who had a gastrectomy for gastric cancer. Which nursing action is appropriate?