The nurse teaches a patient about discharge instructions after a rhinoplasty. Which
statement, if made by the patient, indicates that the teaching was
... [Show More] successful? -
CORRECT ANSWER d. I will keep my head elevated for 48 hours to minimize swelling
and pain.
The nurse plans to teach a patient how to manage allergic rhinitis. Which information
should the nurse include in the teaching plan? - CORRECT ANSWER d. Identification
and avoidance of environmental triggers are the best way to avoid symptoms.
A nurse who is caring for patient with a tracheostomy tube in place has just auscultated
rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action
should the nurse take? - CORRECT ANSWER c. Put on sterile gloves and use a sterile
catheter to suction.
3. The nurse discusses management of upper respiratory infections (URI) with a patient
who has acutesinusitis. Which statement by the patient indicates that additional
teaching is needed? - CORRECT ANSWER c. I can use my nasal decongestant spray
until the congestion is all gone.
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube.
Which action should the nurse include in the plan of care in collaboration with the
speech therapist? - CORRECT ANSWER c. Assess the ability to swallow before using
the fenestrated tube.
The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy
tube. Which action by the nurse would best determine if the cuff has been properly
inflated? - CORRECT ANSWER a. Use a manometer to ensure cuff pressure is at an
appropriate level.
Which statement by the patient indicates that the teaching has been effective for a
patient scheduled for radiation therapy of the larynx? - CORRECT ANSWER a. I will
need to buy a water bottle to carry with me.
A nurse obtains a health history from a patient who has a 35 pack-year smoking history.
The patient
complains of hoarseness and tightness in the throat and difficulty swallowing. Which
question is most important for the nurse to ask? - CORRECT ANSWER a. How much
alcohol do you drink in an average week?
A patient scheduled for a total laryngectomy and radical neck dissection for cancer of
the larynx asks the nurse, Will I be able to talk normally after surgery? What is the best
response by the nurse? - CORRECT ANSWER You will have a permanent opening
into your neck, and you will need to have rehabilitation for
some type of voice restoration.
HESI med surg 2 test banks
A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related
to loss of control of personal care. Which information obtained by the nurse is the best
indicator that this identified problem is
resolving? - CORRECT ANSWER c. The patient asks how to clean the tracheostomy
stoma and tube.
The nurse completes discharge instructions for a patient with a total laryngectomy.
Which statement by the patient indicates that additional instruction is needed? -
CORRECT ANSWER a. I must keep the stoma covered with an occlusive dressing at
all times.
Which action should the nurse take first when a patient develops a nosebleed? -
CORRECT ANSWER a. Pinch the lower portion of the nose for 10 minutes.
A nurse is caring for a patient who has had a total laryngectomy and radical neck
dissection. During the
first 24 hours after surgery what is the priority nursing action? - CORRECT ANSWER d.
Keep the patient in semi-Fowlers position.
Following a laryngectomy a patient coughs violently during suctioning and dislodges the
tracheostomy tube. Which action should the nurse take first? - CORRECT ANSWER b.
Attempt to reinsert the tracheostomy tube with the obturator in place.
Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first? -
CORRECT ANSWER a. A 23-year-old who is complaining of a sore throat and has a
muffled voice
The nurse obtains the following assessment data on an older patient who has influenza.
Which information will be most important for the nurse to communicate to the health
care provider? - CORRECT ANSWER b. Diffuse crackles in the lungs
Which nursing action could the registered nurse (RN) working in a skilled care hospital
unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring
for a patient with a permanent
tracheostomy? - CORRECT ANSWER b. Suction the tracheostomy when needed.
The nurse is caring for a hospitalized older patient who has nasal packing in place to
treat a nosebleed. Which assessment finding will require the most immediate action by
the nurse? - CORRECT ANSWER The oxygen saturation is 89%.
After being hit by a baseball, a patient arrives in the emergency department with a
possible nasal fracture. Which finding by the nurse is most important to report to the
health care provider? - CORRECT ANSWER Clear nasal drainage
A 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 [Show Less]