Nokea
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.
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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.
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 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 obtains the following assessment data for a patient who has influenza. Which of the following information is most important to communicate to the health care provider?
- A. Temperature of 38 C (100.4 F)
- B. Diffuse crackles in the lungs
- C. Sore throat and frequent cough
- D. Myalgia and persistent headache
Correct Answer: B
Rationale: The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical symptoms of influenza and are treated with supportive care measures such as over-the-counter (OTC) pain relievers and increased fluid intake.
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.