Ch.29 EAQ

Which antianxiety drug has the shortest duration of action? Diazepam Morphine Cevimeline Lorazepam

Ans:D Lorazepam Rationale: Lorazepam is an antianxiety drug of short duration and has a low number of respiratory side effects. Diazepam is also an antianxiety drug, but it is not a short-duration drug and causes respiratory depression. Morphine and cevimeline are not antianxiety drugs. Morphine is used for pain management of neck and head cancers. Cevimeline is used for xerostomia; it acts as a saliva stimulant.

A patient is scheduled for surgical removal of a neck tumor followed by radiation treatments. The patient asks the nurse why radiation therapy is not performed prior to the surgery. How does the nurse respond? "Radiation therapy slows tissue healing." "Radiation therapy causes tissue edema." "Radiation therapy increases the risk of metastasis." "Radiation therapy compromises respiratory function."

Ans: A "Radiation therapy slows tissue healing." Rationale: Radiation treatment slows tissue healing and is generally done after surgery. It is not withheld until after surgery because of tissue edema or changes in respiratory function. Radiation does not increase the risk of metastasis.

Which factor is least likely to be monitored during a sleep study for a patient suspected of having sleep apnea? Hypertension Muscle movement Respiratory efforts Heart abnormalities

Ans: A Hypertension Rationale: Hypertension is a long-term effect of sleep apnea and is not important to monitor in a patient being diagnosed for sleep apnea. During a sleep study, muscle movement, respiratory efforts, and abnormal heart conditions are monitored.

Which is the least likely effect of sleep apnea on body metabolism? Increased pH Impaired gas exchange Impaired chest movement Increased blood carbon dioxide levels

Ans: A Increased pH Rationale: The retention of carbon dioxide in sleep apnea causes a decrease in pH levels. Sleep apnea involves impaired gas exchange, impaired chest movement, and increased carbon dioxide levels that lead to respiratory acidosis.

The nursing assistant has taken vital signs of the ventilated postoperative patient who has had radical neck surgery. What does the nurse tell the assistant to be especially vigilant for? Effective pain management Decreased level of consciousness Continuous oozing of bright-red blood Heart rate and blood pressure trending up over several hour

Ans:C Continuous oozing of bright-red blood Rationale: Bright-red blood indicates a rupture in the carotid artery and requires immediate attention. A ventilated postoperative patient will be sedated, so a decreased level of consciousness is to be anticipated. Effective pain management should be evaluated during assessment of vital signs and that information relayed to the nurse. Changes in vital signs, including trends, need to be reported to the nurse responsible for the patient's care. Increasing heart rate and blood pressure can be an indication that the patient is not adequately sedated or is in pain or anxious, for example.

Which surgical procedure is performed if a patient's lymph nodes, sternocleidomastoid muscle, jugular vein, and 11 th cranial nerve have to be removed? Tracheostomy Neck dissection Total laryngectomy Partial laryngectomy

Ans: B Neck dissection Rationale: Neck dissection includes removal of the lymph nodes, sternocleidomastoid muscle, jugular vein, 11 th cranial nerve, and surrounding soft tissues. Tracheostomy helps to safeguard the airway. Total laryngectomy separates the upper airway from the throat and esophagus, and a permanent laryngectomy stoma is created. In partial laryngectomy, a part of the larynx or voice box is removed.

What clinical manifestation related to respiratory difficulty does the nurse expect to observe in a patient who has experienced laryngeal trauma? Nasal flaring Increased nasopharyngeal secretions Poor response to humidification of oxygen Decreased oxygen saturation and CO 2 levels

Ans: A Nasal flaring Rationale: Laryngeal trauma is likely to cause obstruction of the trachea. Nasal flaring is a manifestation of the body's attempt to compensate and bring in more oxygen. If the patient cannot compensate and bring in adequate oxygen, the saturation level will gradually decrease. The CO 2 level will most likely increase. Humidification may be indicated for long-term use, especially for high-flow oxygen, but poor response to humidification is not a manifestation of respiratory difficulty. Increased nasopharyngeal secretions would not necessarily be present as a result of laryngeal trauma.

A postoperative patient develops stridor and becomes short of breath immediately following a thyroidectomy. What action does the nurse take? Notify the Rapid Response Team. Contact the provider to order a chest X-ray. Elevate the head of the bed to a 30-degree angle. Teach the patient to hold the breath while swallowing.

Ans: A Notify the Rapid Response Team. Rationale: Vocal cord paralysis can occur following a thyroidectomy, and the combination of stridor and dyspnea is an emergency requiring endotracheal intubation or tracheostomy. The Rapid Response Team would be notified immediately. A chest X-ray may be performed if aspiration is suspected after the patient is stabilized. Elevating the head of bed to 30 degrees is not a definitive intervention for a patient with a compromised airway. Teaching the patient to hold the breath while swallowing is appropriate for a patient with vocal cord paralysis who is stable.

A newly hired RN with no previous emergency department (ED) experience has just completed a 1-month orientation. Which of these patients would be most appropriate to assign to this nurse? Patient on warfarin with epistaxis with profuse bleeding Patient with suspected bilateral vocal cord paralysis and stridor Patient with facial burns caused by a mattress fire while sleeping Patient with possible facial fractures after a motor vehicle collision (MVC)

Ans: A Patient on warfarin with epistaxis with profuse bleeding Rationale: The initial treatment for epistaxis is upright positioning with direct lateral pressure to the nose. A nurse with minimal ED experience could be expected to safely provide care for this patient. In addition, laboratory work should be obtained to assess the patient's ability to clot, given that the patient is on warfarin. A patient who has sustained facial burns in an enclosed setting is at high risk for airway involvement and requires observation by an experienced nurse. An experienced nurse should take care of a patient with possible facial fractures after an MVC due to the potential for airway compromise from bleeding or swelling. Facial fractures may be accompanied by cervical spine fracture and/or spinal trauma that require monitoring and evaluation by an RN with experience. Stridor is an indication of respiratory distress; this requires an RN with experience.

Which nursing action will decrease the risk of aspiration in a patient with head and neck cancer who has undergone a supraglottic partial laryngectomy? Positioning the patient upright for all meals and medications Starting the patient on clear liquids before advancing the diet Maintaining the nasogastric/feeding tube for adequate nutrition Having the patient take multiple swallows of liquid with each bite of food

Ans: A Positioning the patient upright for all meals and medications Rationale: Upright positioning is an important intervention to decrease the risk of aspiration in patient with head and neck cancer during eating and drinking. The presence of a nasogastric/feeding tube actually increases the risk of aspiration as it interferes with the normal swallowing mechanism. In addition, taking multiple swallows of liquid with each bite of food "to wash it down" does not improve eating and actually increases the risk for aspiration. Evidence has shown that thickening the consistency of all liquids will help to decrease the risk of aspiration and improve swallowing.

Which of the patient's actions during self-management after a laryngectomy can lead to complications? Swimming Using saline on the stoma Cleaning the stoma with water Covering the stoma while coughing

Ans: A Swimming Rationale: Swimming should be avoided after laryngectomy to prevent an infection pathway related to the stoma. Crusting around the stoma should be prevented with a saline solution rinse of the area. The stoma should be cleaned with mild soap and water to prevent infection. The stoma should be covered while coughing because the pressure can cause mucus secretions.

Which factors assist the nurse in determining if fluid leaking from the nose is cerebrospinal fluid (CSF) or normal nasal secretions? Select all that apply. Positive glucose test on a dipstick Yellow halo ring on filter paper as the fluid dries Characteristic color of the fluid on the nasal pack Report by the patient of a "weird" taste in the mouth Fluid that only drains from one side of the patient's nose

Ans: A,B Positive glucose test on a dipstick. Yellow halo ring on filter paper as the fluid dries Rationale: When patients have experienced facial trauma, it may be difficult to visually differentiate clear nasal drainage from a CSF leak. CSF contains glucose and will test positive on a dipstick for glucose. In addition, when CSF dries on filter paper, a yellow halo ring will appear around the dried fluid. Taste changes may occur for a variety of reasons, including medications, and are not indicative of CSF leaks. Both CSF and nasal drainage have a similar appearance on the nasal pack. Unilateral or bilateral drainage of fluid does not identify the source.

A patient has sustained a traumatic brain injury and is mechanically ventilated. Which statement indicates a safety issue and should be addressed by the nurse? An adequate cough reflex will protect the patient's airway. Poor oral hygiene can lead to respiratory crisis from secretions. A tracheotomy will interfere with the patient's ability to communicate. The patient may not realistically expect to regain normal speech with vocal cord damage.

Ans: B Poor oral hygiene can lead to respiratory crisis from secretions. Rationale: Many patients with traumatic brain injury (TBI) cannot perform their oral care unassisted and will potentially experience buildup of secretions and drying of the mucous membranes if they are mouth-breathing. Large amounts of accumulated and dried secretions can actually contribute to airway obstruction. Vocal cord damage is not usually directly associated with TBI. Tracheotomy is not always needed with TBI. Although a cough reflex is important to protect the patient's airway, it does not negate the need for good oral hygiene.

Which principles guide the nurse's support of the patient and family after a complete surgical laryngectomy? Select all that apply. Aspiration cannot occur because the airway and esophagus have been completely separated. The impact on quality of life is often poorly addressed by health care providers in the hospital. Aspiration of food and liquids during swallowing will increase the risk for bronchial pneumonia. With adequate speech and language training, communication can be understandable and meaningful. Learning to swallow may be painful initially; persistence and emotional support are important.

Ans: A,B,D,E Aspiration cannot occur because the airway and esophagus have been completely separated. The impact on quality of life is often poorly addressed by health care providers in the hospital.With adequate speech and language training, communication can be understandable and meaningful.Learning to swallow may be painful initially; persistence and emotional support are important. Rationale: Due to complete removal of the larynx, aspiration is not possible; therefore, aspiration of food and liquids during swallowing is not a concern. Swallow therapy is an important aspect of care during this time; learning to swallow may be painful and will require extensive support. Patients may develop bronchial pneumonia for other reasons and should be encouraged to maintain good bronchial hygiene. Multiple care needs during the postoperative acute phase often interfere with health care team members adequately hearing and addressing quality of life concerns. One important approach would be to connect the patient/family with community-based support resources and addressing their concerns as the patient stabilizes. Speech is also an important component of postoperative care and long-term management so that the patient can communicate with clarity and confidence.

The nurse anticipates obstructive sleep apnea (OSA) in a patient. Which patient statements support this diagnosis? Select all that apply. "I feel sleepy during the day." "I smoke five cigars every day." "I have difficulty falling asleep." "I experience headaches frequently." "I am unable to concentrate on my work."

Ans: A,B,E "I feel sleepy during the day." "I smoke five cigars every day.""I am unable to concentrate on my work." Rationale: The causes of OSA include smoking, obesity, a large uvula, or a short neck. The patient with sleep apnea may experience excessive sleep during the day, lack of concentration, and irritability. Difficulty falling asleep and frequent headaches are not usually associated with OSA.

Which is not a cause of sleep apnea? Obesity Alcohol Smoking Short neck

Ans: B Alcohol Rationale: Alcohol does not contribute to sleep apnea. Obesity, which is a result of unhealthy lifestyle practices, contributes to sleep apnea. Smoking is another major factor that leads to sleep apnea. Anatomical abnormalities, such as a short neck, also contributes to sleep apnea.

A patient has been diagnosed with nasal fracture. What measure does the nurse plan to initiate immediately upon admission to prevent complications? Prevention of a major posterior bleed Assessment for an airway obstruction Prevention of life-threatening infections Decreasing the risk of aspiration when eating

Ans: B Assessment for an airway obstruction Rationale: Prompt recognition of an airway obstruction provides the opportunity to remedy the problem early. Although the other answers all address potential problems in patients with upper respiratory disorders, the immediate need at time of admission is to confirm and maintain a patent airway.

An emergency nurse is preparing to care for a patient arriving by ambulance after a motor vehicle crash. The patient has severe facial and neck injuries and emergency airway measures are taken. Which type of airway does the nurse prepare for? Tracheotomy Cricothyroidotomy Endotracheal intubation Nasal bi-level positive airway pressure (BiPAP)

Ans: B Cricothyroidotomy Rationale: Cricothyroidotomy is an emergency procedure performed by emergency medical personnel to hold an airway open until a tracheotomy may be performed. ET intubation is not likely in a patient with severe head and neck injuries. Nasal BiPAP depends on a patent upper airway. Tracheotomy is a surgical, not a field, procedure.

The nurse answers a patient's call light and realizes that the patient has an upper airway obstruction. What should be the nurse's first action? Attempt to remove the obstruction. Determine the cause of the obstruction. Call the Rapid Response Team to intubate immediately. Call the Rapid Response Team to perform an emergency cricothyroidotomy.

Ans: B Determine the cause of the obstruction. Rationale: The first step the nurse should take is to determine the cause of the obstruction. After the cause has been determined (e.g., tongue, food, inflammation), the nurse can decide the next course of action. The obstruction cannot be removed until its origin has been determined. Although notifying the Rapid Response Team is important and the patient may require intubation, this is not the first action. An emergency cricothyroidotomy is not the first step to take in relieving an upper airway obstruction. This is an invasive procedure that requires specialized training and equipment that is not readily available at the bedside.

Which surgical treatment has a high cure rate with a normal resulting voice quality? Laser surgery Laryngofissure Total laryngectomy Transoralcordectomy

Ans: B Laryngofissure Rationale: Laryngofissure has a high cure rate and the resulting voice quality is normal. In laser surgery, the resulting voice quality may be normal or hoarse. In total laryngectomy, the patient has no natural voice. Transoralcordectomy may lead to a normal or hoarse voice quality.

Which is an orbital-zygoma fracture? Le fort II Le fort III Nasal fracture Maxillary fracture

Ans: B Le fort III Rationale: A Le fort III is an orbital-zygoma fracture called a craniofacial disjunction. A Le fort II is a maxillary and nasoethmoid complex fracture. Nasal and maxillary fractures are simple fractures of the bones after which they are named.

Which diagnostic study is used to differentiate normal tissue from diseased tissue? Computed tomography Magnetic resonance imaging Positron emission tomography Single-photon emission computerized tomography

Ans: B Magnetic resonance imaging Rationale: Magnetic resonance imaging (MRI) is used to differentiate normal tissue from diseased tissue. Computed tomography helps to analyze a tumor's exact location. Positron emission tomography and single-photon emission computerized tomography help to locate additional tumor sites.

Which principle about anterior versus posterior nasal bleeding must the nurse consider the priority? Anterior bleeding is more likely related to a vessel in a nasal polyp. Posterior bleeding is an emergency because it cannot be easily reached. The stimulus that triggered the initial nasal bleeding must be determined. Include the amount and color of nasal drainage in any documentation.

Ans: B Posterior bleeding is an emergency because it cannot be easily reached. Rationale: Posterior bleeding is not as readily seen or as easy to treat with the application of pressure or ice, thus posterior bleeds are more likely to require emergency treatment. Anterior bleeding is more easily seen and treated with pressure. Documentation is important with both types of bleeds; however, it is more difficult to assess the amount of bleeding with a posterior bleed, and blood is more likely to be swallowed. Various stimuli can trigger a nosebleed and sometimes no trigger can be identified.

Which clinical manifestation in the patient with facial trauma is the nurse's first priority? Pain Stridor Bleeding Decreased visual acuity

Ans: B Stridor Rationale: Stridor is an indication of a partial airway obstruction and requires immediate attention. Although bleeding is important in all trauma patients, it is not the first priority in assessing the ABCs. The question does not specify where the bleeding is occurring. The type (venous or arterial) and quantity of the bleeding need to be noted. Visual acuity will be assessed in the secondary survey because it is not considered life-threatening. Pain must be addressed to fully evaluate a patient and complete a reliable examination; however, it is not the nurse's first priority.

Which surgical intervention can be implemented when the patient's sleep apnea is very severe? Uvulectomy Tracheostomy Adenoidectomy Uvulopalatopharyngoplasty

Ans: B Tracheostomy Rationale: Tracheostomy may be used to treat very severe sleep apnea. Uvulectomy, adenoidectomy, and uvulopalatopharyngoplasty are the surgeries which are implemented for more moderate sleep apnea.

Which factor is least likely to be considered while assessing a patient's nutritional status? Sparse hair Unusual bleeding Generalized edema Change in muscle mass

Ans: B Unusual bleeding Rationale: Unusual bleeding is not a factor related to nutrition. Hair quality is decreased due to poor nutritional status. Generalized edema may occur due to inadequate nutritional intake. Decreased muscle mass decrease can be due to poor nutrition.

When caring for a patient with head and neck cancer following a total laryngectomy 12 hours ago, which potential complications are important for the nurse to address? Select all that apply. Preparing the patient for radiation Wound breakdown and hemorrhage Comfort and nonverbal communication Airway obstruction and inadequate oxygenation Educating the patient about various types of chemotherapy

Ans: B,C,D Wound breakdown and hemorrhage. Comfort and nonverbal communication. Airway obstruction and inadequate oxygenation Rationale: Significant potential complications after surgery for head and neck cancer include wound breakdown, airway obstruction/compromise, pain management, and adequate nonverbal communication. This is an extremely stressful time for patients and their families; attentiveness to these aspects of the recovery process can prevent complications and delayed recovery. Once the patient is past the early postoperative period, preparation for teaching about radiation therapy will be needed if it is a recommended treatment. The nurse will not teach a patient about chemotherapy unless this is the prescribed course of treatment. It is also not a priority during the early postoperative period.

A patient has received packing for a posterior nosebleed. In reviewing the patient's orders, which order does the nurse question? "Provide humidified air." "Suction at the bedside." "Give ibuprofen 800 mg every 8 hours as needed for pain." "Encourage bedrest, with the head of the bed elevated 45 to 60 degrees."

Ans: C "Give ibuprofen 800 mg every 8 hours as needed for pain." Rationale: Ibuprofen is contraindicated in a patient with a nosebleed because NSAIDs inhibit clotting. At least initially, bedrest is suggested because significant amounts of blood may have been lost owing to a posterior nosebleed; elevation of the head of the bed is recommended for patient comfort and to facilitate drainage of secretions. Humidified air and humidified oxygen, if oxygen is ordered, are recommended because dryness of the nasal mucosa is a cause of epistaxis (nosebleed). Any patient who is admitted for epistaxis needs suction at the bedside in the event of further bleeding.

What is the radiation absorbed dose given to patients with small cancers in specific locations while treating them with standard radiation therapy? 2000 to 3000 rad 4000 to 4500 rad 5000 to 7500 rad 8000 to 9000 rad

Ans: C 5000 to 7500 rad Rationale: Small cancers in specific locations require a radiation absorbed dose of 5000 to 7500 rad. A radiation absorbed dose of lesser value (2000 to 3000 rad/4000 to 4500 rad) or more (8000 to 9000 rad) when given to the patients with small cancers in specific locations does not help when treating cancer by standard radiation therapy.

A patient complains of disturbed sleep at night and repeated pauses in breathing. Following a complete physical examination, the nurse expects the patient to be assessed for sleep apnea. Which finding in the physical examination supports the nurse's suspicion? Body mass index 29kg/m 2 Blood sugar level 85mg/dL Blood pressure 140/90 mm Hg Blood carbon dioxide level 24 mEq/L

Ans: C Blood pressure 140/90 mm Hg Rationale: Obstructive sleep apnea (OSA) may increase the risk of hypertension, diabetes, and obesity. The blood pressure reading of 140/90 mm Hg indicates hypertension which may be due to OSA as the patient complains of sleep disturbances. A body mass index (BMI) of 29 kg/m 2 is a normal finding; a BMI above 30 indicates obesity. A blood sugar level of 85 mg/dL is a normal finding. The normal range of blood carbon dioxide level is 23-29 mEq/L; therefore, a level of 24 mEq/L is a normal finding.

The nurse notes that the dressing on the surgical site of a patient who recently received a laryngectomy is oozing bright-red blood. What is the priority action for the nurse? Call the Rapid Response Team and secure the airway. Reinforce the dressing and call the health care provider. Call the Rapid Response Team and stay with the patient. Call the operating room and place constant pressure over the site.

Ans: C Call the Rapid Response Team and stay with the patient. Rationale: Oozing bright-red blood is a sign of a carotid artery leak. The nurse should not touch the area and call the Rapid Response Team immediately. Placing additional pressure on the site could cause immediate rupture of the artery.

The nurse assesses that an unconscious patient is struggling to breathe. What should be the nurse's first action? Suction the oropharynx. Insert an oral airway device. Extend the patient's head and neck. Administer oxygen by nasal cannula.

Ans: C Extend the patient's head and neck. Rationale: Patients who are unconscious often have airway obstruction caused by the tongue falling back or by excessive secretions. The initial step is to extend the head and neck. Inserting an oral or nasal airway device and suctioning may be done next. Once the airway is established, oxygen may be necessary.

A patient has been diagnosed with oral and laryngeal cancer, has completed a course of radiation, and it is now 2 days since a total laryngectomy was performed. The patient had been very anxious about the surgery. Which medications does the nurse expect to find on the home medication list? Ketorolac Diazepam Lorazepam Amitriptyline

Ans: C Lorazepam Rationale: Lorazepam is a short-acting antianxiety medication that would be the most appropriate choice for this patient. Amitriptyline is a tricyclic antidepressant that would not be used specifically for this patient's anxiety. Although diazepam is an effective medication for anxiety, it is more likely to cause respiratory depression; the location of this tumor makes diazepam not the best choice for anxiety. Ketorolac is an NSAID and should not be used before surgery. Ketorolac should be used with caution, or not at all, if the patient is taking medication for anxiety.

The nurse is caring for a patient who is in fixed occlusion for a jaw fracture. The most important reason for the nurse to provide oral care with an electronic irrigation system (WaterPik) several times daily is to prevent which condition? Gingivitis Dental caries Mandibular infection Dry mucous membranes

Ans: C Mandibular infection Rationale: Treatment delay, poor oral care, and tooth infection may contribute to mandibular bone infection, which may require antibiotic therapy and sometimes surgical débridement of the infected bone. Oral care can help to prevent dental caries, gingivitis, and dry oral mucous membranes, but these do not prolong treatment for this patient.

A patient has mild sleep apnea with daytime sleepiness. Which interventions does the nurse anticipate? Select all that apply. Uvulectomy Tracheostomy Weight reduction Modafinil therapy Change in sleeping position

Ans: C,D,E Weight reduction. Modafinil therapy. Change in sleeping position Rationale: A patient with mild sleep apnea may find relief with weight loss, modafinil to stay awake during the daytime, and a change in sleeping position. Uvulectomy is recommended when sleep apnea is more severe and unimproved with milder interventions. Tracheostomy treats very severe sleep apnea.

After assessing a patient, the nurse anticipates narcolepsy in the patient. Which patient statement led the nurse to this conclusion? "I have difficulty falling asleep." "I am experiencing lack of sleep at night." "I feel like I am sleeping for longer hours." "I am experiencing uncontrolled daytime sleep."

Ans: D "I am experiencing uncontrolled daytime sleep." Rationale:Narcolepsy is associated with uncontrolled daytime sleep. Lack of sleep at the night or difficulty falling asleep is associated with insomnia. Sleeping for longer hours may indicate hypersomnia.

The supervising RN asks the graduate nurse how to prevent aspiration when the patient with a recent partial laryngectomy eats. Which response by the graduate nurse indicates a need for further instruction? "I will position the patient upright." "I will thicken all liquids for the patient." "I will provide the patient small, frequent meals." "I will encourage the patient to use a straw for liquids."

Ans: D "I will encourage the patient to use a straw for liquids." Rationale: The patient should be discouraged from swallowing continuously from a straw, which increases risk for aspiration. Using a spoon is better for controlling the volume amount. Meals should be small and frequent with the patient seated in an upright position.

A patient with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first? Plan to teach the patient about treatment with modafinil. Suggest that a nasal mask be used instead of a full facemask. Discuss the use of autotitrating positive airway pressure (APAP). Ask the patient whether CPAP has been used consistently at night.

Ans: D Ask the patient whether CPAP has been used consistently at night. Rationale: The nurse should assess whether the patient has actually consistently been using CPAP at night because patients may have difficulty with the initial adjustment to this therapy. With APAP, the pressures are adjusted continuously depending on the patient's needs; this may be more comfortable for the patient. Modafinil treats narcolepsy or daytime sleepiness; it does not treat the cause of sleep apnea, but it may be used to help some of the side effects of obstructive sleep apnea. A nasal mask may be an option for the patient if he or she is finding the facemask used with CPAP uncomfortable.

What is the priority of care for the nurse when working with patients who are experiencing disorders of the upper respiratory tract? Administering nasal oxygen Monitoring for signs of hypoxia Alleviating the patient's anxiety Ensuring a patent airway to promote oxygenation

Ans: D Ensuring a patent airway to promote oxygenation' Rationale: Maintaining a patent airway is essential to promote adequate oxygenation in patients with upper respiratory tract disorders. Although the other answers listed are part of nursing care for these patients, a patent airway is critical to prevent an emergency respiratory arrest situation. When patients are experiencing hypoxia, the most important thing to check is airway patency. A patient with airway problems is likely to experience anxiety until the problem is alleviated. Administering nasal oxygen will not be beneficial if the airway is not patent.

The nurse is assessing a patient who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse? Edema Sore throat Ecchymosis Excessive swallowing

Ans: D Excessive swallowing Rationale: Excessive swallowing in a patient who has undergone a nasoseptoplasty may indicate posterior nasal bleeding and requires immediate attention. Because of the very vascular nature of the face, ecchymosis is a normal finding in the patient who has undergone a nasoseptoplasty. Edema is a normal reaction to any kind of trauma, including that caused by surgery, so it is not an unexpected finding for this patient. A sore throat is a common side effect of endotracheal intubation.

Which statement about obstructive sleep apnea is correct? Patients with obstructive sleep apnea usually do not sleep at all. Recurrent sleep apnea can result in irreversible brain changes and death. Unless obstructive sleep apnea is treated, patients can develop neurologic apnea. Increased carbon dioxide levels stimulate neural centers to awaken the sleeper.

Ans: D Increased carbon dioxide levels stimulate neural centers to awaken the sleeper. Rationale: When apnea occurs, changes in blood gases awaken the sleeper who repositions to correct the obstruction and then returns to sleep. Patients are able to sleep but do not get restful or deep sleep. Recurrent sleep apnea does not cause irreversible brain changes. Untreated obstructive sleep apnea does not cause neurologic apnea.

Which nursing assessment has the highest priority when caring for a patient with facial trauma? Infection Pain level Self-image Oxygenation

Ans: D Oxygenation Rationale: Facial trauma has the potential to interfere with breathing by occluding the upper airways. The nurse should monitor the patient's oxygenation closely. Assessing for infection, pain level, and self-image are important but are not critical.

Xerostomia is a condition associated with which of the following types of treatment? Biotherapy Chemotherapy Speech therapy Radiation therapy

Ans: D Radiation therapy Rationale: Xerostomia is dryness of the mouth, which occurs with radiation therapy. It occurs when the salivary glands are in the irradiation path. The side effect is long term and may be permanent. Biotherapy effects typically include flu-like symptoms including chills, fever, muscle aches and weakness. The most common effects associated with chemotherapy include fatigue, hair loss, infection, anemia, nausea and vomiting, appetite changes, and constipation. There are no real detrimental conditions associated with speech therapy.

Which procedure involves removal of the hyoid bone? Laser surgery Transoral cordectomy Vertical laryngectomy Supraglottic partial laryngectomy

Ans: D Supraglottic partial laryngectomy Rationale: Supraglottic partial laryngectomy involves removal of the hyoid bone. Laser surgery, transoral cordectomy, and vertical laryngectomy are not associated with the removal of the hyoid bone. Laser surgery reduces the tumor or destroys a tumor completely through laryngoscope. Transoral cordectomy involves cutting off a tumor through laryngoscope. Vertical laryngectomy involves removal of one true cord, one false cord, and one-half of the thyroid cartilage.

Which clinical manifestation requires immediate action by the nurse for a patient with laryngeal trauma? Aphonia Hemoptysis Hoarseness Tachypnea

Ans: D Tachypnea Rationale: Tachypnea is a sign of respiratory distress that may accompany laryngeal trauma; this requires immediate action on the part of the nurse. Aphonia (the inability to produce sound) is a manifestation of laryngeal trauma and may be caused by nerve damage, swelling, cartilage fracture, or other events; it does not require immediate action by the nurse. Hemoptysis (bleeding from the airway) may occur as the result of laryngeal trauma. The quantity needs to be observed; an increase in the amount of bleeding can become an emergency because it affects airway patency. Hoarseness is commonly associated with laryngeal trauma but does not require immediate attention.

What is the purpose of wearing fluoride gel trays during radiation therapy of the mouth? To protect the taste buds on the tongue To keep the mouth moist during treatments To keep the teeth from turning yellow after treatment To prevent radiation scatter when the beam hits metal in the mouth

Ans: D To prevent radiation scatter when the beam hits metal in the mouth Rationale: The gel trays help prevent radiation scatter when the beam hits metal in the mouth. They will not provide additional moisture to the mouth. Gel trays with fluoride are not used to prevent yellowing; fluoride is used to prevent demineralization and to help with uptake of calcium and phosphate ions by the teeth. Gel trays fit over the teeth and do not protect the taste buds on the tongue.

The nurse is suctioning the artificial airway of a patient who has undergone a partial laryngectomy the day before and notes blood-tinged secretions. Which action should the nurse take? Assess for correct placement of the airway and reinsert if needed. Place the patient in an upright position and instruct the patient not to cough. Contact the surgeon immediately to report postoperative hemorrhage. Use Standard Precautions when suctioning and monitor for increased bleeding

Ans: D Use Standard Precautions when suctioning and monitor for increased bleeding Rationale: Secretions may be blood-tinged for 1 to 2 days postoperatively after neck surgery. The nurse should use Standard Precautions and observe for increased bleeding that may be associated with hemorrhage. Blood-tinged secretions do not indicate displacement of the airway. Unless there is increased bleeding, there is no need to notify the surgeon. The patient may need to be in a head-elevated position to minimize swelling, but not because of blood-tinged secretions.

A patient who had a rhinoplasty performed 1 day ago is to be discharged. Which instructions does the nurse include in discharge teaching? Select all that apply. "Try to limit forceful coughing." "Stay in a supine position and move slowly." "You may take aspirin or ibuprofen for pain." "Laxatives may be taken to prevent straining." "Use cool compresses on your nose, eyes, and face." "Do not blow your nose for a few days after packing is removed."

Ans:A,D,E,F "Try to limit forceful coughing.""Laxatives may be taken to prevent straining.""Use cool compresses on your nose, eyes, and face.""Do not blow your nose for a few days after packing is removed." Rationale: For patients who have undergone rhinoplasty, cool compresses help reduce swelling. Bleeding can be caused by Valsalva maneuvers (coughing and straining with bowel movements) and blowing the nose too early in the healing process. Patients should stay in a semi-Fowler's position. Aspirin or NSAIDs should be avoided because they increase the risk for bleeding.

A patient has undergone neck dissection surgery and has a skin flap and a closed surgical drain. The nurse has been monitoring drainage hourly on the first postoperative day and notes a decrease in amount from 20-30 mL hourly to less than 5 mL in 1 hour. The nurse suspects which cause for this decrease in drainage? Displacement of the drain A clot obstructing the drain Edema of surrounding tissues Formation of granulation tissue

Ans:B A clot obstructing the drain Rationale: A sudden decrease in drainage from a wound drain can indicate a clot obstructing drainage from the wound site. Most drains are sutured in place and it is not likely the drain is dislodged. Edema is not a likely cause. Granulation tissue does not begin to form on the first postoperative day.

A patient admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response? "It isn't really that often. It just feels that way." "Because your tongue may be blocking your throat, and you wake up because you are choking." "Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe." "Because your body isn't getting enough oxygen. Not getting enough oxygen is what stimulates you to wake up and breathe."

Ans:C "Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe." Rationale: During sleep, the muscles relax and the tongue and neck structures are displaced with the tongue falling back, causing an upper airway obstruction. This obstruction leads to apnea and increased levels of carbon dioxide. Respiratory acidosis stimulates neural centers in the brain, and the patient awakens, takes a deep breath, and goes back to sleep. After the patient returns to sleep, the cycle may be repeated as often as every 5 minutes as the airway is reobstructed. Too much carbon dioxide, not a lack of oxygen, is the trigger that causes the patient to awaken and breathe. Technically the patient is not choking. Telling the patient he or she isn't really awakening that often minimizes the patient's concern and is not accurate. The patient may be awakening every 5 minutes as the cycle repeats.

What would be the most appropriate surgical intervention for a patient with a nasoethmoid complex fracture? Resorbable devices Inner maxillary fixation Microplating surgical systems Open reduction with internal fixation

Ans:C Microplating surgical systems Rationale: A nasoethmoid complex fracture affects the central upper midface. In microplating surgical systems, the plates are made up of synthetic, inorganic, or biologically organic combinations to fix the bone defect. These plates help in holding bone fragments until new bones are developed. The plates can be removed or placed permanently. Resorbable devices are ineffective for nasoethmoid complex fractures because they are made of plastic that begins to biodegrade after 8 weeks. Inner maxillary fixation is also ineffective for nasoethmoid complex fracture because it is used only for realignment of bones, and then wiring is done to keep the bones in place. Open reduction with internal fixation is mostly used in extensive jaw fractures.

A patient is being transported to the Emergency Department after being involved in a motorcycle accident. The paramedic reports that the patient required a cricothyroidotomy in the field. What does the nurse anticipate when the patient arrives? Intubation via nasal route Oxygen delivery via face mask A tube protruding from the chest wall A tube protruding from a stab wound in the neck

Ans:D A tube protruding from a stab wound in the neck Rationale: A cricothyroidotomy is an emergency procedure performed by emergency medical personnel as a stab wound at the cricothyroid membrane. This procedure is used when it is the only way to secure an airway. Oxygen delivery would occur directly into the tube placed in the opening, and the nurse would not expect to see oxygen being delivered by face mask. Nasotracheal intubation is performed by inserting a tube into the trachea via the nose. Chest tube insertion is typically performed in the hospital setting after physician evaluation.

The nurse is providing preoperative teaching to a patient who is about to undergo a supraglottic partial laryngectomy. The patient asks the nurse whether her voice will be normal after surgery. How does the nurse respond? "Your voice will be permanently hoarse after surgery." "Your voice will be normal after recovering from surgery." "You will not have a natural voice after you recover from surgery." "You will be hoarse after surgery, but your voice may become normal."

Ans:D "You will be hoarse after surgery, but your voice may become normal." Rationale: Patients who have a supraglottic partial laryngectomy may have a normal or a hoarse voice after recovery from surgery since the false cords are removed. Patients who have a total laryngectomy will not have a natural voice. Patients who have a laryngofissure will have a normal voice. Patients who have a hemilaryngectomy will have a hoarse voice.

A new patient arrives in the medical-surgical unit with a flap after a total laryngectomy. The flap appears dusky in color. What should be the nurse's first action? Massage the flap site vigorously. Apply a hot pack over the flap site. Place a tight dressing over the flap. Use a Doppler to assess flow to the area.

Ans:D Use a Doppler to assess flow to the area. Rationale: A complete assessment of the area including Doppler activity of major feeding vessels needs to be completed, and the surgeon must be notified because the patient may have to be returned to the operating room immediately. Neither hot nor cold packs (nor anything, for that matter) should be applied to the flap site. The site is delicate and should not be massaged.