ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 22 : Management of Patients With Upper Respiratory Tract Disorders Questions
Question 1 of 5
The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a patient who is postoperative day 1 following total laryngectomy. How should the nurse respond to this development?
Correct Answer: C
Rationale: The nurse promptly notifies the surgeon of any active bleeding, which can occur at a variety of sites, including the surgical site, drains, and trachea. The drain should not be removed or connected to suction. Supine positioning would exacerbate the bleeding. Vitamin K would not be administered without an order.
Question 2 of 5
The nurse is creating a care plan for a patient who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. What form of alaryngeal communication will likely be chosen?
Correct Answer: C
Rationale: Tracheoesophageal puncture is simple and has few complications. It is associated with high phonation success, good phonation quality, and steady long-term results. As a result, it is preferred over esophageal speech, and electric larynx or ASL.
Question 3 of 5
A patient is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the patients nutrition during treatment?
Correct Answer: C
Rationale: A liquid or soft diet is provided during the acute stage of the disease, depending on the patients appetite and the degree of discomfort that occurs with swallowing. The patient is encouraged to drink as much fluid as possible (at least 2 to 3 L/day). There is no need for increased potassium or protein intake.
Question 4 of 5
A patient has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the patient asks, Does this kind of cancer tend to spread to other parts of the body? What is the nurses best response?
Correct Answer: B
Rationale: The incidence of distant metastasis with squamous cell carcinoma of the head and neck (including larynx cancer) is relatively low. The patients prognosis is determined by the oncologist, but the patient has asked a general question and it would be inappropriate to refuse a response. The nurse must not downplay the patients concerns.
Question 5 of 5
The nurse is performing preoperative teaching with a patient who has cancer of the larynx. After completing patient teaching, what would be most important for the nurse to do?
Correct Answer: C
Rationale: Informational materials (written and audiovisual) about the surgery are given to the patient and family for review and reinforcement. The nurse never gives personal contact information to the patient. Nothing in the scenario indicates that a referral to a social worker or psychologist is necessary. False reassurance must always be avoided.