Nokea
The nurse is caring for a patient with a severe nosebleed. The physician inserts a nasal sponge and tells the patient it may have to remain in place up to 6 days before it is removed. The nurse should identify that this patient is at increased risk for what?
- A. Viral sinusitis
- B. Toxic shock syndrome
- C. Pharyngitis
- D. Adenoiditis
Correct Answer: B
Rationale: A compressed nasal sponge may be used. Once the sponge becomes saturated with blood or is moistened with a small amount of saline, it will expand and produce tamponade to halt the bleeding. The packing may remain in place for 48 hours or up to 5 or 6 days if necessary to control bleeding. Antibiotics may be prescribed because of the risk of iatrogenic sinusitis and toxic shock syndrome.
You may also like to solve these questions
The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a patient who is postoperative day 1 following total laryngectomy. How should the nurse respond to this development?
- A. Remove the patients drain and apply pressure with a sterile gauze.
- B. Assess the patient, reposition the patient supine, and apply wall suction to the drain.
- C. Rapidly assess the patient and notify the surgeon about the patients bleeding.
- D. Administer a STAT dose of vitamin K to aid coagulation.
Correct Answer: C
Rationale: The nurse promptly notifies the surgeon of any active bleeding, which can occur at a variety of sites, including the surgical site, drains, and trachea. The drain should not be removed or connected to suction. Supine positioning would exacerbate the bleeding. Vitamin K would not be administered without an order.
The nurse is caring for a patient in the ED for epistaxis. What information should the nurse include in patient discharge teaching as a way to prevent epistaxis?
- A. Keep nasal passages clear.
- B. Use decongestants regularly.
- C. Humidify the indoor environment.
- D. Use a tissue when blowing the nose.
Correct Answer: C
Rationale: Discharge teaching for prevention of epistaxis should include the following: avoid forceful nose blowing, straining, high altitudes, and nasal trauma (nose picking). Adequate humidification may prevent drying of the nasal passages. Keeping nasal passages clear and using a tissue when blowing the nose are not included in discharge teaching for the prevention of epistaxis. Decongestants are not indicated.
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 teaching a patient with allergic rhinitis about the safe and effective use of his medications. What would be the most essential information to give this patient about preventing possible drug interactions?
- A. Prescription medications can be safely supplemented with OTC medications.
- B. Use only one pharmacy so the pharmacist can check drug interactions.
- C. Read drug labels carefully before taking OTC medications.
- D. Consult the Internet before selecting an OTC medication.
Correct Answer: C
Rationale: Patient education is essential when assisting the patient in the use of all medications. To prevent possible drug interactions, the patient is cautioned to read drug labels before taking any OTC medications. Some Web sites are reliable and valid information sources, but this is not always the case. Patients do not necessarily need to limit themselves to one pharmacy, though checking for potential interactions is important. Not all OTC medications are safe additions to prescription medication regimens.
The occupational health nurse is obtaining a patient history during a pre-employment physical. During the history, the patient states that he has hereditary angioedema. The nurse should identify what implication of this health condition?
- A. It will result in increased loss of work days.
- B. It may cause episodes of weakness due to reduced cardiac output.
- C. It can cause life-threatening airway obstruction.
- D. It is unlikely to interfere with the individuals health.
Correct Answer: C
Rationale: Hereditary angioedema is an inherited condition that is characterized by episodes of life-threatening laryngeal edema. No information supports lost days of work or reduced cardiac function.