Med Surg Exam 3 - Chapter 27

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

Use aspirin for pain relief

Remove the packing later that day

Skip the next does of antihypertensive medication

Avoid vigorous nose blowing and strenuous activity

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.

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.

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

Avoid all intranasal sprays and oral antihistamines

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

Use oral decongestants at bedtime to prevent symptoms during the night

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

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.

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.

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

Monitored every 2 to 3 days

Less than 20 mm Hg or 25 cm H2O

Less than 30 mm Hg or 35 cm H2O

Sufficient to fill the pilot balloon until it is tense

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.

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.

4. 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?

Notify the physician immediately

Place the patient in the prone position to facilitate drainage

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

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

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.

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.

5. A type of tracheostomy tube that prevents speech is

A cuffless

A fenestrated tracheostomy tube

A tube with an inflated foam cuff

A cuffed tube with the cuff deflated

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.

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.

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

Hoarseness

Change in fit of dentures

Mouth ulcers that do not heal

Decreased mobility of the tongue

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.

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.

7. When using a voice prosthesis, the patient

Swallows air using a Valsalva maneuver

Places a vibrating device in the mouth

Places a speaking valve over the stoma

Blocks the stoma entrance with a finger

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.

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.

8. 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)

Antiviral agents to treat influenza

Treatment with antibiotics starting ASAP

A throat culture or rapid strep antigen test

Supportive care including, bland liquids

Comprehensive history to determine possible etiology

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.

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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