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
HESI med surg 2 test banks
action should the nurse take first? - CORRECT ANSWER d. Have the patient occlude
the left nare and blow the nose.
The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans.
Which action is appropriate for the nurse to include in the plan of care? - CORRECT
ANSWER d. Teach patient to swish and swallow prescribed oral nystatin (Mycostatin).
When 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? - CORRECT ANSWER b. Use a swab to
obtain a sample for a rapid strep antigen test.
The 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) - CORRECT
ANSWER a. Decongestants can be used to relieve swelling.
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.
The 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)? - CORRECT ANSWER a. A 76-year-old nursing
home resident
b. A 36-year-old female patient who is pregnant
d. A 30-year-old patient who takes corticosteroids for rheumatoid arthritis
Following assessment of a patient with pneumonia, the nurse identifies a nursing
diagnosis of ineffective airway clearance. Which assessment data best supports this
diagnosis? - CORRECT ANSWER a. Weak, nonproductive cough effort
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which
finding would the nurse expect? - CORRECT ANSWER a. Increased tactile fremitus
A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurses
most appropriate action to promote airway clearance? - CORRECT ANSWER a. Assist
the patient to splint the chest when coughing.
The nurse provides discharge instructions to a patient who was hospitalized for
pneumonia. Which
statement, if made by the patient, indicates a good understanding of the instructions? -
CORRECT ANSWER b. I will continue to do the deep breathing and coughing
exercises at home.
HESI med surg 2 test banks
The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which
nursing action will be most effective? - CORRECT ANSWER b. Place patients with
altered consciousness in side-lying positions.
A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3
days. Which
assessment data obtained by the nurse indicates that the treatment has been effective?
- CORRECT ANSWER c. The patients white blood cell (WBC) count is 9000/L.
The health care provider writes an order for bacteriologic testing for a patient who has a
positive
tuberculosis skin test. Which action should the nurse take? - CORRECT ANSWER c.
Teach about the need to get sputum specimens for 2 to 3 consecutive days.
A patient is admitted with active tuberculosis (TB). The nurse should question a health
care providers order to discontinue airborne precautions unless which assessment
finding is documented? - CORRECT ANSWER d. Three sputum smears for acid-fast
bacilli are negative.
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB).
Which statement, if made by the patient, indicates that teaching was effective? -
CORRECT ANSWER b. My husband will be sleeping in the guest bedroom.
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports
having orange
discolored urine and tears. Which is the best response by the nurse? - CORRECT
ANSWER c. Explain that orange discolored urine and tears are normal while taking this
medication.
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse
should notify the health care provider if the patient exhibits which finding? - CORRECT
ANSWER a. Yellow-tinged skin
An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which
intervention by the nurse will be most effective in ensuring adherence with the treatment
regimen? - CORRECT ANSWER d. Arrange for a daily noon meal at a community
center where the drug will be administered.
After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin),
pyrazinamide
(PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast
bacilli (AFB). Which action should the nurse take next? - CORRECT ANSWER b. Ask
the patient whether medications have been taken as directed
Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration
and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse [Show Less]