ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 29 Questions
Question 1 of 5
The nurse is caring for a patient who has had an anterior packing for severe epistaxis. Which of the following nursing interventions should be included in the plan of care?
Correct Answer: A
Rationale: The patient should be instructed to return in 48-72 hours to have the anterior packing removed. Maintaining the head in an elevated position is not required. NSAIDs increase the risk for bleeding and should not be used. Although return to a preinjury appearance is the goal, it is not always possible to achieve this result and the nurse should not provide false reassurance.
Question 2 of 5
The nurse is teaching a patient with allergic rhinitis about management of the condition. Which of the following information should the nurse include in the teaching plan?
Correct Answer: D
Rationale: The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Nonsedating antihistamines are available OTC.
Question 3 of 5
The nurse is providing teaching to a patient who has acute viral rhinitis about management of upper respiratory infections (URI). Which of the following patient statements indicate that additional teaching is needed?
Correct Answer: C
Rationale: The nurse should clarify that nasal decongestant sprays should be used for no more than 5 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.
Question 4 of 5
An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which of the following actions by the student requires the RN to intervene?
Correct Answer: B
Rationale: Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other student actions do not require intervention by the RN. Although the patient may not need 1 minute of preoxygenation, this would not be unsafe. Suctioning for 10 seconds is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube, but the range is 13-15 cm for most adult patients.
Question 5 of 5
The nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow. Which of the following actions should the nurse implement?
Correct Answer: C
Rationale: The patient's mouth and trachea should be suctioned before the cuff is deflated to prevent aspiration of oral secretions. The amount of air needed to inflate the cuff varies and is adjusted by measuring cuff pressure or using the minimal leak technique, not by measuring the volume of air removed from the cuff. The cuff is deflated during patient exhalation so that secretions will be forced into the mouth rather than aspirated. There is no need to clean the inner cannula before cuff deflation.