HESI med surg 2 test banks

HESI med surg 2 test banks The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was 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. 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