Lewis Chapter 27

The nurse enters the room of a patient who has just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. The nasogastric (NG) tube is disconnected from suction and clamped off. b. The patient is in a side-lying position with the head of the bed flat. c. The Hemovac in the neck incision contains 200 mL of bloody drainage. d. The patient is coughing blood-tinged secretions from the tracheostomy

ANS: B, D, C, A The patient should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the Hemovac should be drained because the 200 mL of drainage will decrease the amount of suction in the Hemovac and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting. DIF: Cognitive Level: Analysis REF: 532-534 | 538-539 OBJ: Special Questions: Alternate Item Format, Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiologi

The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to treat a nosebleed. Which of the following assessment findings will require the most immediate action by the nurse? a. The oxygen saturation is 89%. b. The nose appears red and swollen. c. The patient's temperature is 100.1° F (37.8° C). d. The patient complains of level 7 (0 to 10 scale) pain.

ANS: A Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to assess further for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the fall in O2 saturation. DIF: Cognitive Level: Application REF: 520 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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?"

ANS: A Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients also will complain of pain and fever. DIF: Cognitive Level: Application REF: 535 | 538 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

Which of these patients in the respiratory disease clinic should the nurse assess first? a. A 23-year-old, complaining of a sore throat, who has a "hot potato" voice b. A 34-year-old who has a "scratchy throat" and a positive rapid strep antigen test c. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed

ANS: A The patient's clinical manifestation of a "hot potato" voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems. DIF: Cognitive Level: Analysis REF: 528 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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."

ANS: A The stoma may be covered with clothing or a loose dressing, but this is not essential. The other patient comments are all accurate and indicate that the teaching has been effective. DIF: Cognitive Level: Application REF: 542 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective? a. "I will need to buy a water bottle to carry with me." b. "I should not use any lotions on my neck and throat." c. "Until the radiation is complete, I may have diarrhea." d. "Alcohol-based mouthwashes will help clean oral ulcers."

ANS: A Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on irradiated skin, although they should not be used just before the radiation therapy. DIF: Cognitive Level: Application REF: 538 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

The teaching plan for a patient with acute sinusitis will need to include which of the following interventions (select all that apply)? a. Taking a hot shower will increase sinus drainage and decrease pain. b. Over-the-counter (OTC) antihistamines can be used to relieve congestion and inflammation. c. Saline nasal spray can be made at home and used to wash out secretions. d. Blowing the nose forcefully should be avoided to decrease nosebleed risk. e. You will be more comfortable if you keep your head in an upright position.

ANS: A, B, C, E The steam and heat from a shower will help thin secretions and improve drainage. Antihistamines can be used. Patients can use either OTC sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions. DIF: Cognitive Level: Analysis REF: 526-527 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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.

ANS: B Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal capillaries. A firm pilot balloon indicates that the cuff is inflated but does not assess for overinflation. A health care provider's order is not required to determine safe cuff pressure. A minimal leak technique is an alternate means for cuff inflation, but this technique does allow a small air leak around the cuff and increases the risk for aspiration. DIF: Cognitive Level: Application REF: 530 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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.

ANS: B Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other student actions do not require intervention by the RN. Although the patient may not need 1 minute of preoxygenation, this would not be unsafe. Suctioning for 10 seconds is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube, but 5 inches would be appropriate for most adult patients. DIF: Cognitive Level: Comprehension REF: 530 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN/LVN who is caring for a patient with a permanent tracheostomy? a. Assessing the patient's risk for aspiration b. Suctioning the tracheostomy when needed c. Educating the patient about self-care of the tracheostomy d. Determining the need for replacement of the tracheostomy tube

ANS: B Suctioning of a stable patient can be delegated to LPN/LVNs. Assessments and patient teaching should be done by the RN. DIF: Cognitive Level: Application REF: 532-534 | 542 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

The nurse obtains the following assessment data in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider? a. Fever of 100.4° F (38° C) b. Diffuse crackles in the lungs c. Sore throat and frequent cough d. Myalgia and persistent headache

ANS: B The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical symptoms of influenza and are treated with supportive care measures such as over-the-counter (OTC) pain relievers and increased fluid intake.

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.

ANS: B The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area somewhat, but will not be sufficient to stop bleeding. Cauterization or nasal packing may be needed if pressure to the nares does not stop bleeding, but these are not the first actions to take for nosebleed. DIF: Cognitive Level: Application REF: 520-521 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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.

ANS: B The most important goals posttracheotomy are to maintain the airway and ensure adequate oxygenation. Assessment of the breath sounds is the priority action. Maintenance of the tracheostomy ties, cleaning the inner cannula, and checking for bleeding also are appropriate nursing actions but are not of as high a priority. DIF: Cognitive Level: Application REF: 538-541 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse is reviewing the charts for five patients who are scheduled for their yearly physical examinations in October. Which of the following patients will require the inactivated influenza vaccination (select all that apply)? a. A 56-year-old patient who is allergic to eggs b. A 36-year-old female patient who is pregnant c. A 42-year-old patient who has a 15 pack-year smoking history d. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis e. A 24-year-old patient who has allergies to penicillin and the cephalosporins

ANS: B, D Current guidelines suggest that healthy individuals between 6 months and age 49 receive intranasal immunization with live, attenuated influenza vaccine. Individuals who are pregnant, have chronic medical conditions, or are immunocompromised should receive inactivated vaccine. The corticosteroid use by the 30-year-old increases the risk for infection. Individuals with egg allergies should not receive inactivated flu vaccine because it is made using eggs. DIF: Cognitive Level: Application REF: 524 | 525 OBJ: Special Questions: Alternate Item Format TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

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.

ANS: C Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube. DIF: Cognitive Level: Application REF: 529 | 535 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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."

ANS: C Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness. DIF: Cognitive Level: Application REF: 539-540 | 542 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

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.

ANS: C Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not be taught to remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result. DIF: Cognitive Level: Application REF: 520 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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."

ANS: C The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective. DIF: Cognitive Level: Application REF: 524 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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.

ANS: C The patient's mouth and trachea should be suctioned before the cuff is deflated to prevent aspiration of oral secretions. The amount of air needed to inflate the cuff varies and is adjusted by measuring cuff pressure or using the minimal leak technique, not by measuring the volume of air removed from the cuff. The cuff is deflated during patient exhalation so that secretions will be forced into the mouth rather than aspirated. There is no need to clean the inner cannula before cuff deflation. DIF: Cognitive Level: Application REF: 534 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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.

ANS: D The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Nonsedating antihistamines are available OTC. DIF: Cognitive Level: Application REF: 521-523 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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."

ANS: D Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible. DIF: Cognitive Level: Application REF: 541 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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.

ANS: A The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. The patient should be placed in a semi-Fowler's position if reinsertion of the tracheostomy tube is not successful. DIF: Cognitive Level: Application REF: 531 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity