Nokea
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.
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The nurse is caring for a patient with an uncuffed tracheostomy tube who coughs violently during suctioning and dislodges the tracheostomy tube. Which of the following actions should the nurse take first?
- A. Insert the obturator and attempt to reinsert the tracheostomy tube.
- B. Position the patient in an upright position with the neck extended.
- C. Assess the patient's oxygen saturation and notify the health care provider.
- D. Ventilate the patient with a manual bag until the health care provider arrives.
Correct Answer: A
Rationale: The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. The patient should be placed in a semi-Fowler's position if reinsertion of the tracheostomy tube is not successful.
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 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.
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.
Which of the following nursing actions should the nurse perform when suctioning a tracheostomy?
- A. Insert tube 13-15 cm while suctioning.
- B. Withdraw catheter in a straight line while applying intermittent suction.
- C. Limit suction time to 10 seconds.
- D. Oxygenate the patient once all suctioning is completed.
Correct Answer: C
Rationale: Suction time should not exceed 10 seconds. The tube is inserted 13-15 cm but not while suctioning. Suction is done intermittently while withdrawing the catheter but not in a straight line; the catheter should be rotated when withdrawing. Oxygenating the patient after each tube insertion rather than when suctioning is completed.