Nokea
A 42-year-old patient is admitted to the ED after an assault. The patient received blunt trauma to the face and has a suspected nasal fracture. Which of the following interventions should the nurse perform?
- A. Administer nasal spray and apply an occlusive dressing to the patients face.
- B. Position the patients head in a dependent position.
- C. Irrigate the patients nose with warm tap water.
- D. Apply ice and keep the patients head elevated.
Correct Answer: D
Rationale: Immediately after the fracture, the nurse applies ice and encourages the patient to keep the head elevated. The nurse instructs the patient to apply ice packs to the nose to decrease swelling. Dependent positioning would exacerbate bleeding and the nose is not irrigated. Occlusive dressings are not used.
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The campus nurse at a university is assessing a 21-year-old student who presents with a severe nosebleed. The site of bleeding appears to be the anterior portion of the nasal septum. The nurse instructs the student to tilt her head forward and the nurse applies pressure to the nose, but the students nose continues to bleed. Which intervention should the nurse next implement?
- A. Apply ice to the bridge of her nose
- B. Lay the patient down on a cot
- C. Arrange for transfer to the local ED
- D. Insert a tampon in the affected nare
Correct Answer: D
Rationale: A cotton tampon may be used to try to stop the bleeding. The use of ice on the bridge of the nose has no scientific rationale for care. Laying the client down on the cot could block the clients airway. Hospital admission is necessary only if the bleeding becomes serious.
The nurse is providing patient teaching to a patient diagnosed with acute rhinosinusitis. For what possible complication should the nurse teach the patient to seek immediate follow-up?
- A. Periorbital edema
- B. Headache unrelieved by OTC medications
- C. Clear drainage from nose
- D. Blood-tinged mucus when blowing the nose
Correct Answer: A
Rationale: Patient teaching is an important aspect of nursing care for the patient with acute rhinosinusitis. The nurse instructs the patient about symptoms of complications that require immediate follow-up. Referral to a physician is indicated if periorbital edema and severe pain on palpation occur. Clear drainage and blood-tinged mucus do not require follow-up if the patient has acute rhinosinusitis. A persistent headache does not necessarily warrant immediate follow-up.
The nurse is performing an assessment on a patient who has been diagnosed with cancer of the larynx. Part of the nurses assessment addresses the patients general state of nutrition. Which laboratory values would be assessed when determining the nutritional status of the patient?
- A. White blood cell count
- B. Protein level
- C. Albumin level
- D. Platelet count
- E. Glucose level
Correct Answer: B,C,E
Rationale: The nurse also assesses the patients general state of nutrition, including height and weight and body mass index, and reviews laboratory values that assist in determining the patients nutritional status (albumin, protein, glucose, and electrolyte levels). The white blood cell count and the platelet count would not normally assist in determining the patients nutritional status.
The nurse is creating a care plan for a patient who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. What form of alaryngeal communication will likely be chosen?
- A. Esophageal speech
- B. Electric larynx
- C. Tracheoesophageal puncture
- D. American sign language (ASL)
Correct Answer: C
Rationale: Tracheoesophageal puncture is simple and has few complications. It is associated with high phonation success, good phonation quality, and steady long-term results. As a result, it is preferred over esophageal speech, and electric larynx or ASL.
The nurse is providing care for a patient who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize?
- A. The patients swallowing ability
- B. The patients airway patency
- C. The patients carotid pulses
- D. Signs and symptoms of infection
Correct Answer: B
Rationale: The patient with a laryngectomy is at risk for airway occlusion and respiratory distress. As in all nursing situations, assessment of the airway is a priority over other potential complications and assessment parameters.