Med Surg Test 5

Evaluate the flap every hour for the first 72 hours.

A patient has had neck dissection surgery with a reconstructive flap over the carotid artery. Which intervention is appropriate for the flap care?

Performing a tracheotomy

A patient arrives in the emergency department with a severe crush injury to the face with blood gurgling from the mouth and nose and obvious respiratory distress. The nurse prepares to assist the physician with which procedure to manage the airway?

Crepitus

A patient enters the emergency department after being punched in the throat. What does the nurse monitor for?

Suctioning the mouth with an oral suction device

A patient has been transferred from the intensive care unit to the medical-surgical unit after a laryngectomy. What does the nurse suggest to encourage the patient to participate in self-care?

Makes a plan to contact the American Cancer Society Visitor Program

A patient has demonstrated anxiety since a di- agnosis of neck cancer. The surgery and radia- tion therapy are completed. Which behavior indicates that the patient's fears are decreasing?

Wire cutters

A patient has had an inner maxillary fixation for a mandibular fracture. Which piece of equipment should be kept at the bedside at all times?

Examine the throat for bleeding.

On postoperative assessment, the nurse notes that the patient with a rhinoplasty repeatedly swallows. What is the nurse's first action?

Use saline spray to add moisture and prevent rebleeding. Avoid vigorous nose blowing. Do not take aspirin-containing products or NSAIDs. No strenuous lifting for at least a month

Packing has been removed from a patient with epistaxis. Which discharge instructions would the nurse be sure to teach the patient and his family? Select all that apply.

This medication will promote daytime wakefulness.

A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, How will this medication help me? How should the nurse respond?

Make sure you clean the humidifier to prevent infection.

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this clients teaching?

Tuck the chin down when swallowing.

A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration?

Continuous positive airway pressure (CPAP) to deliver a positive airway pressure

A patient has been diagnosed with airway obstruction during sleep. The nurse will likely include patient education about which device for home use?

Side effects of hypoxemia, hypercapnia, and sleep deprivation

A patient has been diagnosed with sleep apnea. Which assessment findings indicate that the patient is having complications associated with sleep apnea?

Positions self upright before eating or drinking anything

A patient has had surgery for cancer of the neck. Which behavior indicates that the patient understands how to perform self-care to prevent aspiration?

You will need to cut the wires if you start vomiting. b. Eat six soft or liquid meals each day while recovering. c. Irrigate your mouth every 2 hours to prevent infection. d. Sleep in a semi-Fowlers position after the surgery.

A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this clients teaching? (Select all that apply.)

Seek immediate medical attention for the bleeding

A patient had a rhinoplasty and is preparing for discharge home. A family member is instructed by the nurse to monitor the patient for postnasal drip by using a flashlight to look in the back of the throat. If bleeding is noted, what does the nurse tell the family member to do?

Milkshakes

A patient has an inner maxillary fixation. The nurse encourages the patient to eat which kind of food?

Collect the nasal drainage on a piece of filter paper.

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?

Hypertension Leukemia. Cocaine use

A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.)

Stridor Ecchymosis behind the ear

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.)

A. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing.d. Ask the client to open his or her mouth.

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.)

Ask the client if he or she has ever been evaluated for sleep apnea.

A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first?Collect the nasal drainage on a piece of filter paper.

A 55-year-old woman who is 50 pounds overweight

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?

Ask the client to gargle with mouthwash containing lidocaine.

A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first

This is normal after surgery. What types of food do you like to eat?

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond?

Make sure the string is taped to the clients cheek.

A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first?

Standard Precautions

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first?

Assist the client to choose a communication method.

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery?

Airway patency

A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?

24-year-old with a traumatic brain injury c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.)

"It is important for your surgeon to know about this information."

A patient has sustained a mandible fracture and the surgeon has explained that the repair will be made using a resorbable plate. The patient discloses to the nurse that he has not told the surgeon about his substance abuse and il- licit drug dependence. What is the nurse's best response?

Apply oxygen and stay with the patient.

A patient in the emergency department with laryngeal trauma has developed shortness of breath with stridor and decreased oxygen saturation. What is the priority action?

Gag and cough reflexes

A patient is admitted for a posterior nose- bleed. Posterior packing is in place and the patient is on oxygen therapy, antibiotics, and opioid analgesics. What is the priority assessment?

Lorazepam

A patient is experiencing acute anxiety related to hospitalization stress and an inability to accept changes related to laryngeal cancer. The patient wants to leave the hospital but agrees to try a medication to "help me calm down." For which medication does the nurse obtain a prn order?

"I will help the patient with a saline gargle."

A patient is having radiation therapy to the neck and reports a sore throat and difficulty swallowing. Which statement by the nursing student indicates a correct understanding of symptom relief for this patient?

No bolus feedings are given at night. Elevate the head of the bed during and after feedings. Evaluate the patient's tolerance of the feedings. Allow the patient to indicate when he or she is ready for the next bite.

A patient is receiving enteral feedings and a nasogastric tube is in place. In order to pre- vent aspiration, which precautions are used? Select all that apply.

Allow extra time to accomplish ADLs because of communication limitations.

A patient is unable to speak following a cordectomy. Which action is delegated to the un-licensed assistive personnel (UAP) to assist the patient in dealing with communication issues?

Place the patient in a semi-Fowler's position and assess for aspiration.

A patient returns from surgery following a rhinoplasty. The unlicensed assistive personnel (UAP) places the patient in a supine position to encourage rest and sleep. Which action should the nurse take first?

Confused and disoriented, difficulty producing sounds, pulse oximetry 80%

A patient who was in a motor vehicle accident and sustained laryngeal trauma is being treated in the emergency department with hu- midified oxygen and is being monitored every 15-30 minutes for respiratory distress. Which assessment finding indicates the urgent need for further intervention?

"What did the doctor say to you about your condition?"

A patient with a recent diagnosis of sinus cancer states that he wants another course of antibiotics because he believes he simply has another sinus infection. What is the nurse's best response?

Have the patient sit upright with the head forward

A patient with an active nosebleed (epistaxis) is admitted to the emergency department. Which intervention does the nurse use first?

Oral care Use of wire cutters Communication Aspiration prevention Dental liquid diet

A patient with facial trauma has undergone surgical intervention to wire the jaw shut. In performing discharge teaching with this patient, which topics does the nurse cover? Select all that apply.

A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago An 88-year-old with esophageal cancer who is awaiting gastric tube placement

A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.)

Airway management

After being treated in the emergency department for posterior nosebleed, the patient is admitted to the hospital. The nasal packing is in place and vital signs are stable. The patient has an IV of normal saline at 125 mL/hr. What is the priority for nursing care?

When I speak, I will whisper rather than use a normal tone of voice.

After teaching a client who is prescribed voice rest therapy for vocal cord polyps, a nurse assesses the clients understanding. Which statement indicates the client needs further teaching?

Abdominal thrusts (Heimlich maneuver)

An older adult patient who is talking and laughing while eating begins to choke on a piece of meat. What is the initial emergency management for this patient?

Provide comprehensive oral care every 2 hours

An older adult with dehydration has altered mental status and inspissated (thickly crusted) oral and nasopharyngeal secretions. What priority instruction would the nurse give to the unlicensed assistive personnel (UAP) when providing care for this patient?

Skin redness and tenderness Difficulty swallowing Hoarseness Dry mouth Impaired taste

Following radiation therapy for head and neck cancer, the nurse instructs the patient about which potential side effects? Select all that

The health care provider and the nurse will assess the patient's ability to swallow.

The health care provider orders the discontinuation of the nasogastric tube for a patient with a total laryngectomy. Before discontinuing the tube, which action must be performed?

Shoulder drop with an increased limitation of movement

The nurse is assessing a patient who has had a neck dissection with removal of muscle tissue, lymph nodes, and the 11th cranial nerve. Which assessment finding is anticipated because of the surgical procedure?

Place a drop of the drainage on a filter paper and look for a yellow ring

The nurse is assessing a patient who reports being struck in the face and head several times. During the assessment, pink-tinged drainage from the nares is observed. Which nursing action provides relevant assessment data?

Restlessness with high-pitched respirations

The nurse is assessing a patient with significant and obvious facial trauma after being struck repeatedly in the face. Which finding is the priority and requires immediate intervention?

Red, tender, and peeling

The nurse is assessing a patient's skin at the site of radiation therapy to the neck. Which skin condition is expected in relation to the radiation treatments?

Administer a stool softener to ease bowel movements

The nurse is caring for a patient who had a nasoseptoplasty. Which action is the best to assign to the licensed practical nurse?

Apply immediate, direct pressure to the site.

The nurse is caring for a patient who had re- constructive neck surgery and observes bright red blood spurting from the tissue flap that is covering the carotid artery. Which action must the nurse take first?

Skull fracture

The nurse is caring for a patient with a nasal fracture. The patient has clear secretions that react positively when tested for glucose. Which complication does the nurse suspect?

The patient has shoulder drop and limited range of motion.

The nurse is caring for a postoperative patient who had a neck dissection. Which assessment finding is expected?

Adequacy of oxygenation; ensure an unobstructed airway

The nurse is caring for several patients who are at risk because of problems related to the upper airway. Which are the priority assessments and actions for these patients?

Supraglottic laryngectomy

The nurse is caring for several patients who re- quire treatment for laryngeal cancer. Which treatment/procedure requires patient educa- tion about aspiration precautions?

"How many servings per day of alcohol do you typically drink?" c. "Have you had a problem with sores in your mouth?" e. "Do you have recurrent laryngitis or frequent episodes of sore throat?" f. "How many packs per day do you smoke and for how many years?"

The nurse is interviewing a patient to assess for risk factors related to head and neck cancer. Which questions are appropriate to include? Select all that apply.

Apply ice to the nasal area and eyes to decrease swelling and pain.

The nurse is providing postoperative nursing care for a patient with surgical correction of a deviated septum. Which intervention is part of the standard care for this patient?

Patients often have changes in the sensations of taste and smell.

The nurse is providing preoperative teaching for a patient who will have a malignant sinus tumor surgically removed. Which key teach- ing point would the nurse be sure to include?

"I will have bruising around my eyes, nose, and face.

The nurse is teaching a patient about post- rhinoplasty care. Which patient statement indicates an understanding of the instruction?

Dynamic swallow study under fluoroscopy

The nurse observes that a patient is having difficulty swallowing and has initiated aspiration precautions. Which procedure does the nurse expect the health care provider to order for this patient?

"I will keep the head of the bed elevated during and after feeding."

The nursing student is caring for an older adult patient who sustained a stroke, is con- fused, and is having trouble swallowing. Which statement by the nursing student indicates an understanding of aspiration precautions for this patient?

It is often seen as white patchy mucosal lesions.

The nursing student is preparing patient teaching materials about head and neck can- cer. Which statement is accurate and included in the patient teaching information?

Change sleeping positions Look into a weight loss program. A position fixing device can prevent tongue subluxation.

The patient has a diagnosis of mild sleep apnea. Which interventions will the nurse teach the patient that may correct this condition? Select all that apply

Notify the health care provider.

The patient with a nasal fracture has clear fluid draining from the nose that dries on a piece of filter paper and leaves a yellow "halo" ring at the dried edge of the fluid. What is the nurse's first action?

A laryngectomy button is shorter and softer than a laryngectomy tube. A laryngectomy button is more comfort- able than a laryngectomy tube. A laryngectomy button requires use of an alternative form of communication.

The patient with a total laryngectomy has a laryngectomy button in place. What important teaching points must the nurse include when teaching the patient about a laryngectomy button? Select all that apply.

Your voice should improve within 4-6 weeks after the radiation therapy is completed." "Typically the hoarseness becomes worse during the radiation therapy." "Rest your voice and use alternative communication methods during radiation therapy." "The speech therapist can offer options for alternative communication methods."

The patient with laryngeal cancer that is being treated with radiation therapy is experiencing hoarseness. What teaching points must the nurse stress with this patient? Select all that apply.

Call the Rapid Response Team (RRT).

The patient with laryngeal trauma develops stridor. What is the nurse's highest priority intervention?

Supraglottic method of swallowing

What does the nurse include in the teaching session for a patient who is scheduled to have a partial laryngectomy?

Radiation therapy

What type of treatment has the highest cure rate for small cancers of the head and neck?

Difficulty swallowing Change in fit of dentures Numbness in the mouth, lips, or face Lump in mouth, neck, or throat

Which are warning signs of head and neck cancer? Select all that apply.

Smoking A short neck Enlarged tonsils or adenoids

Which factors contribute to sleep apnea? Select all that apply.

Limit or avoid straining during bowel movements (e.g., Valsalva maneuver). Do not sniff upwards or blow your nose. Avoid aspirin-containing products or NSAIDs. Use a humidifier to prevent mucosal drying.

Which instructions must the nurse give to a patient after rhinoplasty to prevent bleeding? Select all that apply.

Suggest a moisturizing spray.

Which intervention does the nurse use to assist the patient who suffers from chronic xerostomia secondary to past radiation treatments?

Gas exchange Cellular regulation

Which medical-surgical concepts take priority when the nurse is caring for a patient with a noninfectious upper respiratory problem? Select all that apply.

Fowler's

Which patient with the highest risk for devel- oping cancer of the larynx should be alerted about relevant lifestyle modifications to decrease this risk?

57-year-old male with alcoholism

Which patient with the highest risk for developing cancer of the larynx should be alerted about relevant lifestyle modifications to decrease this risk?

Excessive daytime sleepiness Inability to concentrate Irritability Heavy snoring

Which side effects would a patient with obstructive sleep apnea report? Select all that apply.

"My voice will initially be hoarse but should improve over time."

Which statement by the patient indicates understanding about radiation therapy for neck cancer?

Total laryngectomy

Which surgical procedure of the neck area poses no risk postoperatively for aspiration?

Bloody nasal discharge

Which symptom suggests the possibility of sinus cancer?

Contact the provider and prepare for intubation.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?

Seek medical attention within 24 hours to minimize further complications

While playing football at school, a patient injured his nose, resulting in a possible simple fracture. The patient's parents call the nurse seeking advice. What does the nurse tell the parents to do?