Nokea
The nurse is providing care for a patient who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize?
- A. The patients swallowing ability
- B. The patients airway patency
- C. The patients carotid pulses
- D. Signs and symptoms of infection
Correct Answer: B
Rationale: The patient with a laryngectomy is at risk for airway occlusion and respiratory distress. As in all nursing situations, assessment of the airway is a priority over other potential complications and assessment parameters.
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The campus nurse at a university is assessing a 21-year-old student who presents with a severe nosebleed. The site of bleeding appears to be the anterior portion of the nasal septum. The nurse instructs the student to tilt her head forward and the nurse applies pressure to the nose, but the students nose continues to bleed. Which intervention should the nurse next implement?
- A. Apply ice to the bridge of her nose
- B. Lay the patient down on a cot
- C. Arrange for transfer to the local ED
- D. Insert a tampon in the affected nare
Correct Answer: D
Rationale: A cotton tampon may be used to try to stop the bleeding. The use of ice on the bridge of the nose has no scientific rationale for care. Laying the client down on the cot could block the clients airway. Hospital admission is necessary only if the bleeding becomes serious.
A patient has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to what complication?
- A. Sinus infections
- B. Esophageal strictures
- C. Pharyngitis
- D. Laryngitis
Correct Answer: A
Rationale: Patients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Thus, accurate assessment of patients with these tubes is critical. Use of a nasogastric tube is not associated with the development of the other listed pathologies.
A patient states that her family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to what factor?
- A. Cold viruses are increasingly resistant to common antibiotics.
- B. The virus is shed for 2 days prior to the emergence of symptoms.
- C. A genetic predisposition to viral rhinitis has recently been identified.
- D. Overuse of OTC cold remedies creates a rebound susceptibility to future colds.
Correct Answer: B
Rationale: Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. Antibiotic resistance is not relevant to viral illnesses and OTC medications do not have a rebound effect. Genetic factors do not exist.
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.
The perioperative nurse has admitted a patient who has just undergone a tonsillectomy. The nurses postoperative assessment should prioritize which of the following potential complications of this surgery?
- A. Difficulty ambulating
- B. Hemorrhage
- C. Infrequent swallowing
- D. Bradycardia
Correct Answer: B
Rationale: Hemorrhage is a potential complication of a tonsillectomy. Increased pulse, fever, and restlessness may indicate a postoperative hemorrhage. Difficulty ambulating and bradycardia are not common complications in a patient after a tonsillectomy. Infrequent swallowing does not indicate hemorrhage; frequent swallowing does.