Nokea
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.
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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.
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 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 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 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.