Which client requires the most immediate intervention by the nurse?
1. A client with a maxillary fracture who has been swallowing frequently
2. A client with a temporal bone fracture experiencing hearing loss
3. A client with a fractured nasal bone experiencing a nosebleed
4. A client with a mandibular fracture who has facial numbness and tingling
A client with a maxillary fracture who has been swallowing frequently
Rationale: The client with a maxillary fracture who is swallowing frequently is the priority, as this client is experiencing increased bleeding. This is likely to quickly cause airway obstruction and hemorrhage, especially if a LeFort III maxillary fracture is suspected. Transient hearing loss is common with temporal bone fractures, as these fractures frequently affect the tympanic membrane. The client with the fractured nasal bone will experience a nosebleed, but is not in danger of hemorrhage as is the client with the maxillary fracture. The numbness and tingling in the client with the mandibular fracture is not the priority, as this is expected and transient as the edema of the trigeminal facial nerves dissipates.
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1. Plan to monitor for atrial fibrillation. 2. Plan to monitor the ECG continuously. 3. Plan to take vital signs every 15 minutes. 4. Plan to monitor for hypertension.
Which of the following actions by the nurse would indicate the need for remedial education in the removal of an indwelling catheter?
1. Draping the female client between the thighs 2. Obtaining a specimen before removal 3. Cutting the catheter to deflate the balloon 4. Checking the client's output for 24 hours after removal