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 recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk?
Correct Answer: B
Rationale: Due to the risk for aspiration, the nurse keeps a suction setup available in the hospital and instructs the family to do so at home for use if needed. TPN is not indicated and small meals do not necessarily reduce the risk of aspiration. Physical therapists do not address swallowing ability.
Question 2 of 5
A patient has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to what complication?
Correct Answer: A
Rationale: Patients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Thus, accurate assessment of patients with these tubes is critical. Use of a nasogastric tube is not associated with the development of the other listed pathologies.
Question 3 of 5
A mother calls the clinic asking for a prescription for Amoxicillin for her 2-year-old son who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother?
Correct Answer: B
Rationale: Antimicrobial agents (antibiotics) should not be used because they do not affect the virus or reduce the incidence of bacterial complications. In addition, their inappropriate use has been implicated in development of organisms resistant to therapy. It would be inappropriate to tell the patient that the physician will not respond to her request.
Question 4 of 5
The nurse is providing care for a patient who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize?
Correct Answer: B
Rationale: The patient with a laryngectomy is at risk for airway occlusion and respiratory distress. As in all nursing situations, assessment of the airway is a priority over other potential complications and assessment parameters.
Question 5 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.