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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.
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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.
The nurse is caring for a patient with a tracheostomy who has a new prescription for a fenestrated tracheostomy tube. Which of the following actions should be included in the plan of care?
- A. Leave the tracheostomy inner cannula inserted at all times.
- B. Place the decannulation cap in the tube before cuff deflation.
- C. Assess the ability to swallow before using the fenestrated tube.
- D. Inflate the tracheostomy cuff during use of the fenestrated tube.
Correct Answer: C
Rationale: Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube.
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 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 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.