book & evolve med surg 25-26

pg 233

Which portion of the internal nose traps particles and kills bacteria?

mucus membrane

Which function of the tonsils and adenoids in small children is correct?

• promote antibody formation

• assist in digestive

• protect against bacterial infections of the throat

protect against bacterial infections of the throat

A patient comes into the clinic complaining of runny nose and facial pain. What information should the assessment include?

assessment for nasal drainage and sinus tenderness

Which symptom does age-related relaxation of the esophageal sphincter in a 70-ear old patient cause?

burning in the throat when lying down

A patient with sleep apnea complains about wearing a mask while sleeping. What information should the nurse remind the patient regarding the function of the mask?

it uses positive pressure to keep the airway open

A patient comes into the clinic complaining of waking up with a dry mouth and nose and asks if the dryness has caused the colds she has had in the last few months. Which suggestion is most appropriate to suggest?

• use a humidifier at home

• get a throat culture

• get a nose culture

• request an antibiotic

use a humidifier at home

Which assessment should indicate the necessity for a nurse to suction a patient with a tracheostomy?

becomes restless and an increase in vital signs

Which position is most appropriate for a pt returning from surgery with a nasal pack and mustache dressing?

high-fowler position and apply a cold dressing to reduce swelling

A 90 year-old pt complains to the nurse of sob after walking up a flight of stairs/ Which age-related change should the nurse explain results in this problem?

• flexible rib cage

• high-arched diaphragm

• increased chest movement

• enlarged bronchioles

enlarged bronchioles

Enlarged bronchioles require the inspiration of greater amounts of air.

Which rationale explains the importance of the nurse closely monitoring bilateral breath sound and chest movement after a thoracentesis?

the lung may have been punctured during the procedure

The Allen test assesses?

perfusion of the hand

A patient who is severely dyspenic an cyanotic enters the ER. At which rate should a nurse administer oxygen to the patient?

• 2L to preserve the hypoxic drive

• 6L to relieve the dyspnea

• 8L, humidified, to liquefy secretions

• 10L, humidified, to dilate the bronchi

2L to preserve the hypoxic drive

Which assessment indicates that the chest tube in a water seal drainage device is working correctly?

• constant bubbling in the suction control chamber

• decrease of accumulation in the drainage chamber

• fluctuation of the column of water in the water seal

• constant bubbling in the water seal chamber

fluctuation of the column of water in the water seal

Which assessment by the nurse at the bedside of a patient with a chest tube attached to a water seal drainage device should require intervention?

• dependent loops in the chest tube

• patient in semi-fowler

• changing level of water in the water seal chamber

• increased level of drainage to 20mL in 8 hours

dependent loops in the chest tube

Can collect drainage and occlude the system.

A home health nurse is caring for an 88 year-old pt with severe hypertension and respiratory problems. Which medication should she suggest the pt avoid?

• aspirin

• Colace

• expectorant

• decongestant

decongestant raises bp

In which position should a nurse place a patient who had a left pneumonectomy in an effort to enhance ga exchange?

• on the right side

• on the left side

• in a semi-fowler position

• supine

in a semi-fowler position

Which info correctly explains that the breathing pattern has been altered when a pt complains of tachypnea?

decreased oxygen level signals the phrenic nerve to alter the respiration rate

muscles of respiration respond to the stimulus

A patient complains of morning headaches, a feeling of fullness in her head, and a pain similar to that of a toothache under her eye. Which diagnosis?

• nasal polyps

• impacted wisdom teeth

• allergic rhinitis

• sinusitis

sinusitis

Which initial action of a nurse should be implemented when providing first aid to a person with spontaneous epistaxis?

have the person sit down and lean forward

Which statement is true regarding bacterial pharyngitis that is untrue for viral pharyngitis?

Has an abrupt unset.

Which are the most common causes of layrngitis?

• smoking and highly seasoned foods

• alcohol and voice strain

• nasal congestion and frequent coughing

• respiratory infection and voice strain

• respiratory infection and voice strain

Which is the most significant topic for a nurse to include in a teaching plan for a patient with frequent episodes of laryngitis?

observing voice rest

A patient who had a laryngectomy 3 months earlier returns with the complaint of increasing dyspnea. Which common post laryngectomy complication should the nurse recognize as indicating?

• hypertrophied stoma

• salivary fistula

• carotid blowout

• tracheal stenosis

tracheal stenosis

Which is one of the major post-op difficulties for a patient having a supraglottic laryngectomy?

• teaching the patient to use an assistive device to speak

• coughing without letting food escape through he tracheostomy

• taking care of the tracheostomy since it’ll always be there

• teaching the patient to swallow without aspiration

teaching the patient to swallow without aspiration

A temporary tracheostomy will be closed within _ days?

5

What major problem should the nurse be on alert for with a pt in the recovery room following a tonsillectomy?

hemorrhage

The pt presents to the clinic with ongoing complaints of nasal obstruction. Which factor alerts the nurse that the pat is at risk for a nasal tumor?

pt works in a bakery

Which respiratory disorder does polysomnography diagnose?

• pharyngitis

• nasal tumor

• laryngeal cancer

• obstructive sleep apnea

• obstructive sleep apnea

A pt with a subglottic laryngectomy develops tachycardia, dyspnea, cough, and pink frothy sputum. It is most likely what?

aspiration pneumonia

Which condition would the intervention of humidification be an effective method of treatment?

• nasal polyps

• deviated nasal septum

• nasal congestion & obstruction

• when the pt is a mouth breather

when the pt is a mouth breather

The nurse is working with another to cthe tracheostomy dressing for a mechanically ventilated person. The nurse has removed the old dressing, cleansed the site, and is preparing to apply a fresh dressing and realizes the gauze sponge is not a precut drain sponge. Which intervention is best?

retie the trach ties and get the correct dressing

The nurse is assessing a pt who has signs and symptoms of tb. Which test requires the need for collecting sputum?

acid-fast test

The nurse is caring for an 88 year-old pt who is taking PHENYLEPHRINE PSUEDOPHEDRINE (Sudafed). Which pt characteristic will alert the nurse to the side effects of this medication?

pulse

The nurse is caring for a patient with a tracheostomy. Which action, if preformed by the wife, would indicate an additional teaching?

the cathether is rinsed with warm tap water

Should be normal sterile saline.