Nokea
The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently?
- A. Airway patency
- B. Level of consciousness
- C. Psychological status
- D. Pain level
Correct Answer: A
Rationale: The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation. The priorities are always airway, breathing, and then circulation.
You may also like to solve these questions
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 performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would the nurse ask the client about the use of herbal supplements?
- A. They produce anorexia.
- B. They impair the immune system.
- C. They may prolong bleeding.
- D. They lower high-density lipoprotein levels.
Correct Answer: C
Rationale: The nurse must find out the bleeding tendencies of clients scheduled for tonsillectomy and adenoidectomy. Therefore, the nurse asks the clients about any recent use of herbal supplements. The nurse must ask about the use of thesesupplements because they may prolong bleeding. A client may experience anorexia because of a diminished sense of taste and smell following a laryngectomy. Similarly, excess zinc impairs the immune system and lowers the levels of high-density lipoproteins. These symptoms are not caused by herbal supplements.
A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first?
- A. Call for the registered nurse to reinsert the tube.
- B. Place a dilator in the stoma to maintain the opening.
- C. Cover the tracheostomy site with a sterile gauze to prevent infection.
- D. Transfer the client to the emergency department.
Correct Answer: B
Rationale: If the tracheostomy tube becomes dislodged, a dilator is initially placed to hold the edges of the stoma apart until a physician is able to reinsert the tube. A tracheal tube must never be forced back into place. Covering the tracheostomy sitewith gauze can obstruct the stoma, decreasing ventilation. If needed, transporting the client to the emergency department may occur but not until the airway is stabilized.
The nurse is an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factor(s) would the nurse be sure to include in the workshop? Select all that apply.
- A. Alcohol
- B. Age
- C. Tobacco
- D. Industrial pollutants
- E. Region of country lived in
Correct Answer: A,B,C,D
Rationale: Carcinogens, such as tobacco, alcobol, and industrial pollutants, are associated with laryngeal cancer. The age of the client is also a factor, with a higher incidence among those 65 years of age or older. Region of country lived in is notassociated with laryngeal cancer as a specific risk factor.
The nurse is caring for a client diagnosed with coryza possibly from the rhinovirus. Vital signs are temperature: $101.2^{\circ} \mathrm{F}$, pulse: 72 beats/minute, respirations: 28 breaths/minute, blood pressure: $112 / 70$ $\mathrm{mm} \mathrm{Hg}$. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are coarse in the bases. Which afternoon assessment finding suggests the advancement to an infectious process?
- A. Achiness
- B. Headache
- C. Temperature rise
- D. Increased respiratory rate
Correct Answer: C
Rationale: Coryza refers to the common cold many times associated with a virus such as the rhinovirus. The nurse notes that the client is currently febrile. A rise in the temperature is interpreted that the client continues to have a sustained elevated temperature which suggests a bacterial infection. All viruses can include symptoms of achiness, headache, and an increase in the respiratory rate. Increased respiratory rate does not always indicate infection because it can be a sign of a multitude of other problems.