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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.
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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 who had a total laryngectomy and has a nursing diagnosis of hopelessness related to loss of control of personal care. Which of the following information obtained by the nurse is the best indicator that the problem identified in this nursing diagnosis is resolving?
- A. The patient lets the spouse provide tracheostomy care.
- B. The patient allows the nurse to suction the tracheostomy.
- C. The patient asks how to clean the tracheostomy stoma and tube.
- D. The patient uses a communication board to request 'No Visitors.'
Correct Answer: C
Rationale: Independently caring for the laryngectomy tube indicates that the patient has regained control of self-care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.
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.
An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which of the following actions by the student requires the RN to intervene?
- A. The student preoxygenates the patient for 1 minute before suctioning.
- B. The student puts on clean gloves and uses a sterile catheter to suction.
- C. The student inserts the catheter about 13 cm into the tracheostomy tube.
- D. The student applies suction for 10 seconds while withdrawing the catheter.
Correct Answer: B
Rationale: Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other student actions do not require intervention by the RN. Although the patient may not need 1 minute of preoxygenation, this would not be unsafe. Suctioning for 10 seconds is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube, but the range is 13-15 cm for most adult patients.
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.