When planning care, for which client should the nurse include ...

[AEWBW]

When planning care, for which client should the nurse include close observation for a decreased or absent cough reflex?
 
  1. The client with a nasal fracture
  2. The client with impairment of vagus nerve conduction
  3. The client with a sinus infection
  4. The client with reduction in respiratory membrane conduction

Question 2

The nurse is caring for a client with a fecal incontinence pouch. What should the nurse do when caring for this client?
 
  1. Assess perianal skin.
  2. Irrigate the pouch every shift.
  3. Maintain the drainage system.
  4. Change the bag every 72 hours.
  5. Explain the purpose of the system to the client.

[jsm54321]

Answer to Question 1

Correct Answer: 2
Rationale 1: Nasal fracture does not depress the cough reflex.
Rationale 2: The cough reflex depends upon nerve impulse transmission via the vagus nerve to the medulla. The nurse must monitor clients with vagus nerve impairment (through spinal cord injury, trauma, CNS depression, or other means) for a decreased or absent cough reflex. This decreased or absent reflex places the client at high risk for aspiration or development of pneumonia or other respiratory infections.
Rationale 3: A sinus infection will not depress the cough reflex.
Rationale 4: The respiratory membrane is the alveolar/capillary membrane and is not implicated in decreased or absent cough reflex.

Answer to Question 2

Correct Answer: 1, 3, 4, 5

Rationale 1: For the client with a fecal incontinence pouch, the nurse should regularly assess the perianal skin area.

Rationale 2: Fecal incontinence pouches are not irrigated.

Rationale 3: For the client with a fecal incontinence pouch, the nurse should maintain the drainage system.

Rationale 4: For the client with a fecal incontinence pouch, the nurse should change the bag every 72 hours or sooner if there is leakage.

Rationale 5: For the client with a fecal incontinence pouch, the nurse should explain the purpose of the pouch to the client.

[AEWBW]

TYSM

[atrochim]

Excellent