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 with an uncuffed tracheostomy tube who coughs violently during suctioning and dislodges the tracheostomy tube. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. The patient should be placed in a semi-Fowler's position if reinsertion of the tracheostomy tube is not successful.
Question 2 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 3 of 5
The nurse is teaching a patient with laryngeal cancer about radiation therapy. Which of the following patient statements indicate that the teaching has been effective?
Correct Answer: A
Rationale: Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on irradiated skin, although they should not be used just before the radiation therapy.
Question 4 of 5
Which of the following patients in the respiratory disease clinic should the nurse assess first?
Correct Answer: A
Rationale: The patient's clinical manifestation of stridor suggests partial airway obstruction, a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems.
Question 5 of 5
Which of the following actions should the nurse take first when a patient develops a nosebleed?
Correct Answer: B
Rationale: The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area somewhat, but will not be sufficient to stop bleeding. Cauterization or nasal packing may be needed if pressure to the nares does not stop bleeding, but these are not the first actions to take for nosebleed.