Nokea
The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, 'Elevate the head of the bed 45 degrees.' This assists in meeting which nursing goal?
- A. The client will have decreased pain.
- B. The client will remain alert and oriented.
- C. The client will have decreased edema.
- D. The client will have increased tissue perfusion.
Correct Answer: C
Rationale: Elevating the head of the bed 45 degrees when the client is fully awake decreases surgical edema and increases lung expansion. At this point in the recovery, elevating the head of the bed will not decrease the surgical pain as pain medication will be needed. Elevating the head of the bed will not affect mentation nor increase theblood supply.
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The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose?
- A. CBC with differential
- B. Transillumination of the sinus
- C. Nasal culture
- D. Magnetic resonance imaging (MRI)
Correct Answer: B
Rationale: Transillumination and $x$-rays of the sinuses may show a change in the shape of or confirms that there is fluid in the sinus cavity. CBC with differential can note an elevated white blood cell count but not confirm fluid in the sinus cavity. A nasal culture can note bacteria in the nares. An MRI is an expensive procedure which is not typically prescribed for a potential infection and not specifically ordered to identify fluid in thesinus cavity.
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?
- A. Copious mucous secretions
- B. Sudden restlessness
- C. Harsh cough
- D. Bilateral breath sounds present
Correct Answer: B
Rationale: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube.Bilateral breath sounds are an expected finding; the absence of bilateral breath sounds should be reported to the provider immediately.
A client recently diagnosed with laryngeal cancer and awaiting a laryngectomy was encouraged to attend a support group prior to surgery. The client asked the nurse about the name of the laryngeal speech method where the client speaks with theassistance of a surgically implanted device. The nurse is correct to provide teaching on which method?
- A. Esophageal speech
- B. An artificial larynx
- C. A tracheoesophageal puncture
- D. An electronic voice box
Correct Answer: C
Rationale: A tracheoesophageal puncture is the method where a client speaks with the assistance of a surgically implanted valve that diverts air through the esophagus through a surgical opening in the posterior wall of the trachea with the assistance of a voice prosthesis. Esophageal speech occurs from swallowing air and forming words with the lips. An artificial larynx is a throat vibrator or an apparatus that projectssound into the oral cavity. There is no available electronic voice box.
The nurse is mentoring a new graduate nurse and the two are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. Which complication(s) would the nurse identify for the new nurse? Select all that apply.
- A. Absence of secretions
- B. Aspiration
- C. Infection
- D. Injury to the laryngeal nerve
- E. Penetration of the anterior tracheal wall
Correct Answer: B,C,D
Rationale: The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall.
The nurse is providing tracheostomy care for a client. Place the following steps in the order the nurse should perform them.
- A. Position client in a supine or low Fowler position.
- B. Using a clean glove, remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle.
- C. Open the tracheostomy kit without contaminating the contents. Don sterile gloves- keep the dominant hand sterile. Pour hydrogen peroxide and normal saline into respective containers.
- D. Unlock the inner cannula by turning it counterclockwise. Remove it and place in hydrogen peroxide. Clean the inside and outside of the cannula with pipe cleaners.
- E. Rinse the cleaned cannula with normal saline. Tap the cannula and wipe the excess solution with sterile gauze.
- F. Replace the inner cannula and turn it clockwise within the outer cannula.
- G. Clean around the stoma with an applicator moistened with normal saline.
Correct Answer: C,A,B,D,E,G,F
Rationale: The nurse should position client in a supine or low Fowler position. Using a clean glove, the nurse should remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle. The nurse should then open the tracheostomy kit without contaminating the contents. The nurse should don sterile gloves, keeping the dominant hand sterile. Next, the nurse should pour hydrogen peroxide and normalsaline into respective containers. The nurse should then unlock the inner cannula by turning it counterclockwise, afterward removing it and placing it in hydrogen peroxide. The nurse should clean the inside and outside of the cannula with pipe cleaners. Next, the nurse should rinse the cleaned cannula with normal saline. The nurse should then tap the cannula and wipe the excess solution with sterile gauze. Next, the nurse should replace the inner cannula and turn it clockwise within the outer cannula. The nurseshould then clean around the stoma with an applicator moistened with normal saline.Next, the nurse should place a sterile dressing around the tracheostomy tube andchange the tracheostomy ties by placing the new ones on first and removing the soiled ones last. Finally, the nurse should tie the new ends securely, but not tightly, at theside of the neck. The nurse should perform hand hygiene before, during, and after the procedure.