Med Surg Exam 3 - Chapter 27 | Attempts: 385

1.

A patient was seen in the clinic for an episode of epistaxis, which was controlled by placement of anterior nasal packing. During discharge teaching, the nurse instructs the patient to

A.

Use aspirin for pain relief
B.

Remove the packing later that day
C.

Skip the next does of antihypertensive medication
D.

Avoid vigorous nose blowing and strenuous activity

Correct Answer
D. Avoid vigorous nose blowing and strenuous activity

Explanation
The nurse instructs the patient to avoid vigorous nose blowing and strenuous activity because these actions can increase the risk of bleeding and dislodging the nasal packing. It is important for the patient to take precautions to prevent further bleeding and ensure proper healing of the nasal tissues. Using aspirin for pain relief may increase the risk of bleeding, so it is not recommended. Removing the packing without medical supervision can also lead to complications. Skipping antihypertensive medication is unrelated to the management of epistaxis.

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2.

A patient with allergic rhinitis reports severe nasal congestion, sneezing, and water, itchy eyes and nose at a various times of the year. To teach the patient to control these symptoms, the nurse advises the patient to

A.

Avoid all intranasal sprays and oral antihistamines
B.

Limit the duration of use of nasal decongestant spray to 10 days
C.

Use oral decongestants at bedtime to prevent symptoms during the night
D.

Keep a diary of when the allergic reaction occurs and what precipitates it

Correct Answer
D. Keep a diary of when the allergic reaction occurs and what precipitates it

Explanation
The correct answer is to keep a diary of when the allergic reaction occurs and what precipitates it. This is because keeping a diary will help the patient identify specific triggers that may be causing their symptoms, such as certain allergens or environmental factors. By identifying these triggers, the patient can then take steps to avoid or minimize exposure to them, which can help control their symptoms. Avoiding all intranasal sprays and oral antihistamines, limiting the duration of nasal decongestant spray use, and using oral decongestants at bedtime may be helpful in some cases, but they do not address the underlying cause of the symptoms like keeping a diary does.

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3.

A patient is seen at the clinic with fever, muscle aches, sore throat with yellowish exudate, and headache. The nurse anticipates that the collaborative management will include (select all that apply)

A.

Antiviral agents to treat influenza
B.

Treatment with antibiotics starting ASAP
C.

A throat culture or rapid strep antigen test
D.

Supportive care including, bland liquids
E.

Comprehensive history to determine possible etiology

Correct Answer(s)
C. A throat culture or rapid strep antigen test
D. Supportive care including, bland liquids
E. Comprehensive history to determine possible etiology

Explanation
The patient presents with symptoms commonly associated with a streptococcal infection, such as fever, sore throat with yellowish exudate, and muscle aches. Therefore, a throat culture or rapid strep antigen test is necessary to confirm the presence of streptococcus bacteria. Supportive care, including bland liquids, is important to alleviate symptoms and promote hydration. Additionally, a comprehensive history is needed to determine the possible cause of the symptoms and guide further management. Antiviral agents are not indicated as the symptoms are more consistent with a bacterial infection rather than influenza. Treatment with antibiotics should only be initiated after confirming a bacterial infection through testing.

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4.

A type of tracheostomy tube that prevents speech is

A.

A cuffless
B.

A fenestrated tracheostomy tube
C.

A tube with an inflated foam cuff
D.

A cuffed tube with the cuff deflated

Correct Answer
C. A tube with an inflated foam cuff

Explanation
A tracheostomy tube with an inflated foam cuff prevents speech because the cuff blocks the air passage between the trachea and the vocal cords. This prevents air from passing through the vocal cords, making it difficult or impossible to produce speech. The foam cuff creates a seal around the trachea, which is necessary for certain medical conditions or procedures but restricts airflow for speech.

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5.

To prevent excessive pressure on tracheal capillaries, pressures in the cuff of a trachestomy tube should be

A.

Monitored every 2 to 3 days
B.

Less than 20 mm Hg or 25 cm H2O
C.

Less than 30 mm Hg or 35 cm H2O
D.

Sufficient to fill the pilot balloon until it is tense

Correct Answer
B. Less than 20 mm Hg or 25 cm H2O

Explanation
The correct answer is "less than 20 mm Hg or 25 cm H2O" because excessive pressure on tracheal capillaries can lead to tissue damage and impaired blood flow. Monitoring the pressures in the cuff of a tracheostomy tube every 2 to 3 days helps to ensure that the pressure remains within a safe range. Keeping the pressure below 20 mm Hg or 25 cm H2O helps to prevent complications and maintains adequate blood flow to the tracheal capillaries.

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6.

Which of the following is a late symptom of head and neck cancer?

A.

Hoarseness
B.

Change in fit of dentures
C.

Mouth ulcers that do not heal
D.

Decreased mobility of the tongue

Correct Answer
D. Decreased mobility of the tongue

Explanation
Decreased mobility of the tongue is a late symptom of head and neck cancer. As the cancer progresses, it can invade the surrounding tissues and structures, including the tongue. This invasion can lead to a decrease in the tongue's ability to move properly, causing difficulties in speaking and swallowing. It is important to note that early detection and treatment of head and neck cancer is crucial to prevent the progression of the disease and improve the chances of successful treatment.

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7.

While in the recovery room, a patient with a total laryngectomy is suctioned and has bloody mucus with some clots. Which of the following nursing interventions would apply?

A.

Notify the physician immediately
B.

Place the patient in the prone position to facilitate drainage
C.

Instill 3 mL of normal saline into the tracheostomy tube to loosen secretions
D.

Continue your assessment of the patient, including O2 saturation, respiratory rate, and breath sounds.

Correct Answer
D. Continue your assessment of the patient, including O2 saturation, respiratory rate, and breath sounds.

Explanation
The correct answer is to continue the assessment of the patient, including O2 saturation, respiratory rate, and breath sounds. This is because the patient with a total laryngectomy may experience bloody mucus with clots due to normal post-operative healing. It is important to assess the patient's respiratory status and oxygen saturation to ensure adequate ventilation and oxygenation. Notifying the physician immediately or placing the patient in the prone position may not be necessary or appropriate interventions in this situation. Instilling normal saline into the tracheostomy tube may also not be indicated without further assessment.

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8.

When using a voice prosthesis, the patient

A.

Swallows air using a Valsalva maneuver
B.

Places a vibrating device in the mouth
C.

Places a speaking valve over the stoma
D.

Blocks the stoma entrance with a finger

Correct Answer
D. Blocks the stoma entrance with a finger

Explanation
When using a voice prosthesis, the patient blocks the stoma entrance with a finger. This is because the stoma is a surgical opening in the neck that allows air to pass through the trachea. By blocking the stoma entrance with a finger, the patient can redirect the airflow through the vocal prosthesis, which is a device that helps them produce sound. This allows the patient to speak using the prosthesis and communicate effectively.

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