DeWitt Medical -Surgical Nursing - Chapter 13

DeWitt Medical -Surgical Nursing - Chapter 13 On initial assessment, a patient who just had a tonsillectomy and adenoidectomy is restless and swallows frequently. What is the most likely explanation? 1) Excessive thirst 2) Swelling in the neck 3) Bleeding 4) Soar throat - ANS 3) Bleeding A 45 year old man is eating steak suddenly rises from his seat. His hands are grasping his throat. What actions should be performed? Identify the correct sequence? 1) Position your open hand just above the umbilicus 2) Wrap your arms around the man from behind 3) Deliver upward squeeze thrusts 4) Ask the man if he is choking - ANS 4) Ask the man if he is choking 2) Wrap your arms around the man from behind 1) Position your open hand just above the umbilicus 3) Deliver upward squeeze thrusts When caring for a patient who had rhinoplasty , the nurse should perform which intervention in the immediate postoperative period? Select all that apply 1) Observe for frequent swallowing 2) Monitor amount of drainage on dressing 3) Position patient flat on the back 4) Apply warm compresses 5) Provide humidified oxygen - ANS 1) Observe for frequent swallowing 2) Monitor amount of drainage on dressing 5) Provide humidified oxygen The spouse of a patient with a tracheostomy asks, " what is the purpose of the cuff on the tracheostomy tube?" What is the best response? 1) It holds the tube in place 2) It allows the ventilator to deliver a full breath of air. 3) It prevents the development of pneumonia 4) It reduces the risk for tracheal necrosis - ANS 4) It reduces the risk for tracheal necrosis A patient has sinusitis. Which non pharmacological interventions would be appropriate ? Select all that apply 1) Apply ice packs over the sinus area. 2) Suggest inhalation of moist steam 3) Increase fluids 4) Position with the head lower than the shoulders 5) Rest and reduce stress 6) Use of a sinus irrigation kit. - ANS 2) Suggest inhalation of moist steam 3) Increase fluids 5) Rest and reduce stress 6) Use of a sinus irrigation kit. While deciding whether to sign the surgical consent for tracheostomy, the patients spouse asks, what is the purpose of this procedure? Which response demonstrates nursing knowledge regarding the procedure? Select all that apply 1) The procedure facilitates suctioning of respiratory secretions. 2) The procedure prevents recurrence of respiratory arrest 3) The procedure prevents hospital acquired pneumonia 4) The procedure bypasses an obstructed upper airway 5) The procedure is a temporary airway for face and neck injuries. - ANS 1) The procedure facilitates suctioning of respiratory secretions. 4) The procedure bypasses an obstructed upper airway 5) The procedure is a temporary airway for face and neck injuries. A 55 year old man with a new tracheostomy is unable to cough. Breath sounds are diminished. Pulse oximetry is 88% on 100% humidified air. What is the priority nursing action? 1) Provide positive ventilation 2) Suction respiratory secretions 3) Administer pain medications 4) Humidify inhaled air - ANS 2) Suction respiratory secretions A patient is newly diagnosed with a squamous cell carcinoma of the larynx. What is an early sign and symptom for this diagnosis? 1) Crepitation 2) Hoarseness 3) Frothy sputum 4) Drooling - ANS 2) Hoarseness A student is caring for a patient diagnosed with OSA. he patient is not convinced that the CPAP machine is worth the effort. What is the most important reason for the patient to receive treatment ? 1) Use of the CPAP machine will decrease the risk of pneumonia 2) Use of the CPAP machine will improve energy levels 3) Untreated OSA can lead to heart attack and stroke 4) Untreated OSA can lead to upper airway cancers - ANS 3) Untreated OSA can lead to heart attack and stroke A nurse is caring for a patient who is postoperative for tonsillectomy. Within the first 24 hours , which food item would be most appropriate to offer the patient? 1) Orange juice 2) Warm tea 3) Snack crackers 4) Popsicles - ANS 4) Popsicles