ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 20 Questions
Question 1 of 5
The emergency department nurse is assessing a client following a motor vehicle accident. The nurse notes facial deformities with swelling and bleeding and a clear drainage coming from the nares. Which diagnostic test is completed to determine if the clear drainage is cerebrospinal fluid?
Correct Answer: C
Rationale: When clear drainage is observed from the nares of a client, a Dextrostix is used to determine the presence of glucose which is present in cerebrospinal fluid. A serum CBC would provide information on red and white blood cell count. A low red blood cell count is may be found due to hemorrhage that has occurred. Nitrazine paper is under to assess vaginal secretions for the presence of amniotic fluid. A glucometercheck will provide information on serum glucose, not the glucose level in the cerebrospinal fluid.
Question 2 of 5
The nurse is caring for a client who is post-sinus surgery. When assessing the client, the nurse asks how many the nurse is holding up. Why does the nurse assess postoperative visual acuity?
Correct Answer: B
Rationale: A client who has undergone a sinus surgery faces a serious risk of damage to the optic nerve.
Therefore, the nurse assesses postoperative visual acuity by asking the client to identify the number of fingers displayed.
To assess possible hemorrhage, the nurse observes the client for repeated swallowing. The nurse assesses for pain over the involved sinuses and not a postoperative infection or an impaired drainage.
Question 3 of 5
The nurse is providing tracheostomy care for a client. Place the following steps in the order the nurse should perform them.
Correct Answer: C,A,B,D,E,G,F
Rationale: The nurse should position client in a supine or low Fowler position. Using a clean glove, the nurse should remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle. The nurse should then open the tracheostomy kit without contaminating the contents. The nurse should don sterile gloves, keeping the dominant hand sterile. Next, the nurse should pour hydrogen peroxide and normalsaline into respective containers. The nurse should then unlock the inner cannula by turning it counterclockwise, afterward removing it and placing it in hydrogen peroxide. The nurse should clean the inside and outside of the cannula with pipe cleaners. Next, the nurse should rinse the cleaned cannula with normal saline. The nurse should then tap the cannula and wipe the excess solution with sterile gauze. Next, the nurse should replace the inner cannula and turn it clockwise within the outer cannula. The nurseshould then clean around the stoma with an applicator moistened with normal saline.Next, the nurse should place a sterile dressing around the tracheostomy tube andchange the tracheostomy ties by placing the new ones on first and removing the soiled ones last. Finally, the nurse should tie the new ends securely, but not tightly, at theside of the neck. The nurse should perform hand hygiene before, during, and after the procedure.
Question 4 of 5
The nurse is caring for a client diagnosed with coryza possibly from the rhinovirus. Vital signs are temperature: $101.2^{\circ} \mathrm{F}$, pulse: 72 beats/minute, respirations: 28 breaths/minute, blood pressure: $112 / 70$ $\mathrm{mm} \mathrm{Hg}$. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are coarse in the bases. Which afternoon assessment finding suggests the advancement to an infectious process?
Correct Answer: C
Rationale: Coryza refers to the common cold many times associated with a virus such as the rhinovirus. The nurse notes that the client is currently febrile. A rise in the temperature is interpreted that the client continues to have a sustained elevated temperature which suggests a bacterial infection. All viruses can include symptoms of achiness, headache, and an increase in the respiratory rate. Increased respiratory rate does not always indicate infection because it can be a sign of a multitude of other problems.
Question 5 of 5
A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first?
Correct Answer: B
Rationale: If the tracheostomy tube becomes dislodged, a dilator is initially placed to hold the edges of the stoma apart until a physician is able to reinsert the tube. A tracheal tube must never be forced back into place. Covering the tracheostomy sitewith gauze can obstruct the stoma, decreasing ventilation. If needed, transporting the client to the emergency department may occur but not until the airway is stabilized.