The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems?
(Put a comma and a space between each answer choice A, B, C, D.)
a. The patient is in a side-lying position with the head of the bed flat.
b. The patient is coughing blood-tinged secretions from the tracheostomy.
c. The nasogastric (NG) tube is disconnected from suction and clamped off.
d. The wound drain in the neck incision contains 200 mL of bloody drainage.
Question 2The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)?
a. Decongestants can be used to relieve swelling.
b. Blowing the nose should be avoided to decrease the nosebleed risk.
c. Taking a hot shower will increase sinus drainage and decrease pain.
d. Saline nasal spray can be made at home and used to wash out secretions.
e. You will be more comfortable if you keep your head in an upright position.
Question 3When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6 F (38.7 C), and yellow patches on the tonsils. Which action will the nurse anticipate taking?
a. Teach the patient about the use of expectorants.
b. Use a swab to obtain a sample for a rapid strep antigen test.
c. Discuss the need to rinse the mouth out after using any inhalers.
d. Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs).
Question 4The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)?
a. A 76-year-old nursing home resident
b. A 36-year-old female patient who is pregnant
c. A 42-year-old patient who has a 15 pack-year smoking history
d. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis
e. A 24-year-old patient who has allergies to penicillin and cephalosporins
Question 5A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being stuck up my nose and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first?
a. Notify the clinic health care provider.
b. Obtain aerobic culture specimens of the drainage.
c. Ask the patient about how the cotton got into the nose.
d. Have the patient occlude the left nare and blow the nose.
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