Nokea
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.
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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 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 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.
The nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery, which of the following actions is priority?
- A. Monitor for bleeding.
- B. Assess breath sounds.
- C. Clean the inner cannula every 8 hours.
- D. Avoid changing the tracheostomy ties.
Correct Answer: B
Rationale: The most important goals post-tracheotomy are to maintain the airway and ensure adequate oxygenation. Assessment of the breath sounds is the priority action. Maintenance of the tracheostomy ties, cleaning the inner cannula, and checking for bleeding also are appropriate nursing actions but are not of as high a priority.
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.