Nokea
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.
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The nurse is caring for a patient with an uncuffed tracheostomy tube who coughs violently during suctioning and dislodges the tracheostomy tube. Which of the following actions should the nurse take first?
- A. Insert the obturator and attempt to reinsert the tracheostomy tube.
- B. Position the patient in an upright position with the neck extended.
- C. Assess the patient's oxygen saturation and notify the health care provider.
- D. Ventilate the patient with a manual bag until the health care provider arrives.
Correct Answer: A
Rationale: The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. The patient should be placed in a semi-Fowler's position if reinsertion of the tracheostomy tube is not successful.
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 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.
The nurse is caring for a patient with a tracheostomy who has a new prescription for a fenestrated tracheostomy tube. Which of the following actions should be included in the plan of care?
- A. Leave the tracheostomy inner cannula inserted at all times.
- B. Place the decannulation cap in the tube before cuff deflation.
- C. Assess the ability to swallow before using the fenestrated tube.
- D. Inflate the tracheostomy cuff during use of the fenestrated tube.
Correct Answer: C
Rationale: Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube.
Which of the following causes is the most common cause of acute pharyngitis?
- A. Fungal
- B. Viral
- C. Acute follicular
- D. Peritonsillar
Correct Answer: B
Rationale: Viral pharyngitis accounts for approximately 70% of all cases of acute pharyngitis.