Lewis Chapter 27 Flashcards
After a patient has undergone a rhinoplasty, which nursing intervention will be included in the plan of care?
a. Educate the patient about how to safely remove and reapply nasal packing.
b. Reassure the patient that the nose will look normal when the swelling subsides.
c. Instruct the patient to keep the head elevated for 48 hours to minimize swelling and pain.
d. Teach the patient to use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control.
c. Instruct the patient to keep the head elevated for 48 hours to minimize swelling and pain.
When teaching the patient with allergic rhinitis about management of the condition, the nurse explains that
a. over-the-counter (OTC) antihistamines cause sedation, so prescription antihistamines are usually ordered.
b. corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.
c. use of oral antihistamines for a few weeks before the allergy season may prevent reactions.
d. identification and avoidance of environmental triggers are the best way to avoid symptoms.
d. identification and avoidance of environmental triggers are the best way to avoid symptoms.
After discussing management of upper respiratory infections (URI) with a patient who has acute viral rhinitis, the nurse determines that additional teaching is needed when the patient says
a. “I can take acetaminophen (Tylenol) to treat discomfort.”
b. “I will drink lots of juices and other fluids to stay hydrated.”
c. “I can use my nasal decongestant spray until the congestion is all gone.”
d. “I will watch for changes in nasal secretions or the sputum that I cough up.”
c. “I can use my nasal decongestant spray until the congestion is all gone.”
An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene?
a. The student preoxygenates the patient for 1 minute before suctioning.
b. The student puts on clean gloves and uses a sterile catheter to suction.
c. The student inserts the catheter about 5 inches into the tracheostomy tube.
d. The student applies suction for 10 seconds while withdrawing the catheter.
b. The student puts on clean gloves and uses a sterile catheter to suction.
When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient’s ability to swallow, it is important to
a. clean the inner cannula of the tracheostomy tube before deflation.
b. deflate the cuff during the inhalation phase of the respiratory cycle.
c. suction the patient’s mouth and trachea before deflation of the cuff.
d. insert exactly the same volume of air into the cuff during reinflation.
c. suction the patient’s mouth and trachea before deflation of the cuff.
The nurse is caring for a spontaneously breathing patient who has a tracheostomy. To determine that the patient can protect the airway when eating without having the tracheostomy cuff inflated, the nurse will deflate the cuff and
a. ask the patient to say a few sentences.
b. monitor for signs of respiratory distress.
c. have the patient drink a small amount of grape juice and observe for coughing.
d. auscultate the lungs for crackles after having the patient take a few sips of water.
c. have the patient drink a small amount of grape juice and observe for coughing.
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action will be included in the plan of care?
a. Leave the tracheostomy inner cannula inserted at all times.
b. Place the decannulation cap in the tube before cuff deflation.
c. Assess the ability to swallow before using the fenestrated tube.
d. Inflate the tracheostomy cuff during use of the fenestrated tube.
c. Assess the ability to swallow before using the fenestrated tube.
When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to
a. check the pilot balloon after inflation to ensure that it is firm.
b. use a manometer to ensure cuff pressure is at an appropriate level.
c. check the amount of cuff pressure ordered by the health care provider.
d. fill the balloon until minimal air leakage around the cuff is auscultated.
b. use a manometer to ensure cuff pressure is at an appropriate level.
The nurse is obtaining a health history from a 67-year-old patient with a 40 pack-year smoking history, complaints of hoarseness and tightness in the throat, and difficulty swallowing. Which question is most important for the nurse to ask?
a. “How much alcohol do you drink in an average week?”
b. “Do you have a family history of head or neck cancer?”
c. “Have you had frequent streptococcal throat infections?”
d. “Do you use antihistamines for upper airway congestion?”
a. “How much alcohol do you drink in an average week?”
A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, “How will I talk after the surgery?” The best response by the nurse is,
a. “You will breathe through a permanent opening in your neck, but you will not be able to communicate orally.”
b. “You won’t be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed.”
c. “You won’t be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally.”
d. “You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.”
d. “You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.”
A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that the problem identified in this nursing diagnosis is resolving?
a. The patient lets the spouse provide tracheostomy care.
b. The patient allows the nurse to suction the tracheostomy.
c. The patient asks how to clean the tracheostomy stoma and tube.
d. The patient uses a communication board to request “No Visitors.”
c. The patient asks how to clean the tracheostomy stoma and tube.
After completing discharge instructions for a patient with a total laryngectomy, the nurse determines that additional instruction is needed when the patient says,
a. “I must keep the stoma covered with a loose sterile dressing at all times.”
b. “I can participate in most of my prior fitness activities except swimming.”
c. “I should wear a Medic Alert bracelet that identifies me as a neck breather.”
d. “I need to be sure that I have smoke and carbon monoxide detectors installed.”
a. “I must keep the stoma covered with a loose sterile dressing at all times.”
Which action should the nurse take first when a patient develops a nosebleed?
a. Pack both nares tightly with 1/2-inch ribbon gauze.
b. Pinch the lower portion of the nose for 10 minutes.
c. Prepare supplies that will be needed for cauterization.
d. Apply ice compresses over the patient’s nose and cheeks.
b. Pinch the lower portion of the nose for 10 minutes.
When the nurse is caring for a patient who has had a total laryngectomy and radical neck dissection during the first 24 hours after surgery, what is the priority nursing action?
a. Monitor for bleeding.
b. Assess breath sounds.
c. Clean the inner cannula every 8 hours.
d. Avoid changing the tracheostomy ties.
b. Assess breath sounds.
A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?
a. Insert the obturator and attempt to reinsert the tracheostomy tube.
b. Position the patient in an upright position with the neck extended.
c. Assess the patient’s oxygen saturation and notify the health care provider.
d. Ventilate the patient with a manual bag until the health care provider arrives.
a. Insert the obturator and attempt to reinsert the tracheostomy tube.
