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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.
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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 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 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.
The nurse is teaching a patient with allergic rhinitis about management of the condition. Which of the following information should the nurse include in the teaching plan?
- A. Over-the-counter (OTC) antihistamines cause sedation, so prescription antihistamines are usually ordered.
- B. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use
- C. Use of oral antihistamines for a few weeks before the allergy season may prevent reactions.
- D. Identification and avoidance of environmental triggers are the best ways to avoid symptoms.
Correct Answer: D
Rationale: The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Nonsedating antihistamines are available OTC.