Nokea
The nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow. Which of the following actions should the nurse implement?
- A. Clean the inner cannula of the tracheostomy tube before deflation.
- B. Deflate the cuff during the inhalation phase of the respiratory cycle.
- C. Suction the patient's mouth and trachea before deflation of the cuff.
- D. Insert exactly the same volume of air into the cuff during reinflation.
Correct Answer: C
Rationale: The patient's mouth and trachea should be suctioned before the cuff is deflated to prevent aspiration of oral secretions. The amount of air needed to inflate the cuff varies and is adjusted by measuring cuff pressure or using the minimal leak technique, not by measuring the volume of air removed from the cuff. The cuff is deflated during patient exhalation so that secretions will be forced into the mouth rather than aspirated. There is no need to clean the inner cannula before cuff deflation.
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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.
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.
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 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 caring for a patient who is scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx. The patient asks the nurse, 'How will I talk after the surgery?' Which of the following responses by the nurse is best?
- A. You will breathe through a permanent opening in your neck, but you will not be able to communicate orally.
- B. You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed.
- C. You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally.
- D. You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.
Correct Answer: D
Rationale: Voice restoration is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.