Nokea
The nurse is caring for a patient who has had an anterior packing for severe epistaxis. Which of the following nursing interventions should be included in the plan of care?
- A. Educate the patient to return in 3 days to have the nasal packing removed.
- 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 pain
- D. Teach the patient to use nonsteroidal anti-inflammatory drugs (NSAIDS) for pain control.
Correct Answer: A
Rationale: The patient should be instructed to return in 48-72 hours to have the anterior packing removed. Maintaining the head in an elevated position is not required. NSAIDs increase the risk for bleeding and should not be used. Although return to a preinjury appearance is the goal, it is not always possible to achieve this result and the nurse should not provide false reassurance.
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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.
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.
An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which of the following actions 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 13 cm into the tracheostomy tube.
- D. The student applies suction for 10 seconds while withdrawing the catheter.
Correct Answer: B
Rationale: 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 the range is 13-15 cm for most adult patients.
The nurse is obtaining a health history from a patient with a 40 year, pack a day smoking history, symptoms of hoarseness and tightness in the throat, and difficulty swallowing. Which of the following questions 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?
Correct Answer: A
Rationale: 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.
The nurse is caring for a hospitalized older adult patient who has posterior 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 37.8 C (100 F)
- D. The patient complains of level 7 (0-10 scale) pain.
Correct Answer: A
Rationale: 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.