Nokea
The nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery, which of the following actions is priority?
- A. Monitor for bleeding.
- B. Assess breath sounds.
- C. Clean the inner cannula every 8 hours.
- D. Avoid changing the tracheostomy ties.
Correct Answer: B
Rationale: The most important goals post-tracheotomy 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.
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The nurse is providing discharge instructions for a patient with a total laryngectomy. Which of the following patient statements indicate that additional instruction is required?
- 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.
Correct Answer: A
Rationale: 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.
The nurse is providing teaching to a patient who has acute viral rhinitis about management of upper respiratory infections (URI). Which of the following patient statements indicate that additional teaching is needed?
- A. I can take acetaminophen 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.
Correct Answer: C
Rationale: The nurse should clarify that nasal decongestant sprays should be used for no more than 5 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.
Which of the following actions should the nurse take first when a patient develops a nosebleed?
- A. Pack both nares tightly with 1 cm 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.
Correct Answer: B
Rationale: 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.
Which of the following nursing actions should the nurse perform when suctioning a tracheostomy?
- A. Insert tube 13-15 cm while suctioning.
- B. Withdraw catheter in a straight line while applying intermittent suction.
- C. Limit suction time to 10 seconds.
- D. Oxygenate the patient once all suctioning is completed.
Correct Answer: C
Rationale: Suction time should not exceed 10 seconds. The tube is inserted 13-15 cm but not while suctioning. Suction is done intermittently while withdrawing the catheter but not in a straight line; the catheter should be rotated when withdrawing. Oxygenating the patient after each tube insertion rather than when suctioning is completed.
The nurse is caring for a patient with a tracheostomy tube and is inflating the cuff to the appropriate level. Which of the following actions is best for the nurse to implement?
- 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.
Correct Answer: B
Rationale: 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 over-inflation. 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.