Nokea
The nurse is preparing a teaching plan for a patient with acute sinusitis. Which of the following interventions should be included in the plan? (Select all that apply.)
- A. Taking a hot shower will increase sinus drainage and decrease pain.
- B. Over-the-counter (OTC) decongestants can be used as required.
- C. Saline nasal spray can be made at home and used to wash out secretions.
- D. Blowing the nose forcefully should be avoided to decrease nosebleed risk.
- E. You will be more comfortable if you keep your head in an upright position.
Correct Answer: A,B,C,E
Rationale: The steam and heat from a shower will thin secretions and improve drainage. Antihistamines can be used. Patients can use either OTC sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.
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Which of the following patients in the respiratory disease clinic should the nurse assess first?
- A. A 23-year-old, complaining of a sore throat, who has stridor
- B. A 34-year-old who has a 'scratchy throat' and a positive rapid strep antigen test
- C. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue
- D. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed
Correct Answer: A
Rationale: The patient's clinical manifestation of stridor suggests partial airway obstruction, a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems.
The nurse is caring for a patient who had a total laryngectomy and has a nursing diagnosis of hopelessness related to loss of control of personal care. Which of the following information obtained by the nurse is the best indicator that the problem identified in this nursing diagnosis is resolving?
- A. The patient lets the spouse provide tracheostomy care.
- B. The patient allows the nurse to suction the tracheostomy.
- C. The patient asks how to clean the tracheostomy stoma and tube.
- D. The patient uses a communication board to request 'No Visitors.'
Correct Answer: C
Rationale: Independently caring for the laryngectomy tube indicates that the patient has regained control of self-care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.
The nurse is teaching a patient with laryngeal cancer about radiation therapy. Which of the following patient statements indicate that the teaching has been effective?
- A. I will need to buy a water bottle to carry with me.
- B. I should not use any lotions on my neck and throat.
- C. Until the radiation is complete, I may have diarrhea.
- D. Alcohol-based mouthwashes will help clean oral ulcers.
Correct Answer: A
Rationale: Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on irradiated skin, although they should not be used just before the radiation therapy.
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.
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.