NRNP 6540 Midterm Test Bank |
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‣ A patient whose tracheostomy was inserted 30 minutes ago is
recovering in the postanesthesia recovery unit when the tracheostomy
tube is expelled by coughing. What is the priority action by the nurse?
A. Suction the tracheostomy opening.
B. Maintain the airway with a sterile hemostat.
C. Use an Ambu bag and mask to ventilate the patient.
D. Insert the tracheostomy tube obturator into the stoma. -✓✓B.
Maintain the airway with a sterile hemostat.
Rationale:
As long as the patient is not in acute respiratory distress after dislodging
the tracheostomy tube, the nurse should use a sterile hemostat to
maintain an open airway until a sterile tracheostomy tube can be
reinserted into the tracheal opening. The tracheostomy is an open
surgical wound that has not had time to mature into a stoma. If the
patient is in respiratory distress, the nurse will use an Ambu bag and
mask to ventilate the patient temporarily.
‣ The nurse is reviewing the health history of a patient with laryngeal
cancer. Which finding would the nurse expect?
A. Family history of lung cancer
B. Recent inhalation of noxious fumes
C. Frequent straining of the vocal cords
D. Chronic use of alcohol and tobacco products -✓✓D. Chronic use of
alcohol and tobacco products
,rationale:
Tobacco use causes 85% of head and neck cancers. Excess alcohol use is
another major risk factor. Other risk factors include exposure to the sun,
asbestos, industrial carcinogens, marijuana use, radiation therapy to the
head and neck, and poor oral hygiene.
‣ A patient is being discharged from the emergency department after
being treated for epistaxis. In teaching first aid measures in the event the
epistaxis would recur, what measures should the nurse suggest? (Select
all that apply.)
A. Tilt patient's head backwards.
B. Apply ice compresses to the nose.
C. Tilt head forward while sitting upright.
D. Pinch the entire soft lower portion of the nose.
E. Lying down until 15 minutes after the bleeding ceases -✓✓C. Tilt
head forward while sitting upright.
D. Pinch the entire soft lower portion of the nose.
rationale:
Use simple first aid measures to control nosebleeds. These include: (1)
placing the patient in a sitting position, leaning slightly forward with
head tilted forward and (2) applying direct pressure by squeezing the
entire soft lower portion of the nose (nostrils) together for 5 to 15
minutes. Tilting the head back does not stop the bleeding but allows the
blood to enter the nasopharynx, which could result in aspiration or
nausea or vomiting from swallowing blood. Lying down also will not
decrease the bleeding.
‣ The nurse observes clear nasal drainage in a patient newly admitted
with facial trauma with a nasal fracture. What is the nurse's priority
action?
,A. Test the drainage for the presence of glucose.
B. Suction the nose to maintain airway clearance.
C. Document the findings and continue monitoring.
D. Apply a drip pad and reassure the patient this is normal. -✓✓A. Test
the drainage for the presence of glucose.
Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The
drainage should be tested for the presence of glucose, which would
indicate the presence of CSF. Suctioning should not be done.
Documenting the findings and monitoring are important after notifying
the health care provider. A drip pad may be applied, but the patient
should not be reassured that this is normal.
‣ A patient had an open reduction repair of a bilateral nasal fracture. The
nurse plans to implement an intervention that focuses on both nursing
and medical goals for this patient. Which intervention should the nurse
implement?
A. Apply an external splint to the nose.
B. Insert plastic nasal implant surgically.
C. Humidify the air for mouth breathing.
D. Maintain surgical packing in the nose. -✓✓D. Maintain surgical
packing in the nose.
Rationale:
A goal that is common to nursing and medical management of a patient
after rhinoplasty is to prevent the formation of a septal hematoma and
potential infections resulting from a septal hematoma. Therefore, the
nurse helps to keep the nasal packing in the nose. The packing applies
direct pressure to oozing blood vessels to stop postoperative bleeding. A
medical goal includes realigning the fracture with an external or internal
splint. The nurse helps maintain the airway by humidifying inspired air
, because the nose is unable to do so following surgery because it is
swollen and packed with gauze.
‣ The nurse is scheduled to administer seasonal influenza vaccinations to
the residents of a long-term care facility. What would be a
contraindication to the administration of the vaccine to a resident?
A. Age older than 80 years
B. History of upper respiratory infections
C. Chronic obstructive pulmonary disease (COPD)
D. History of a severe allergic reaction to the vaccine -✓✓D. History of
a severe allergic reaction to the vaccine
Rationale:
Contraindications to vaccination include a history of severe allergic
reactions to previous flu vaccine. Patients with anaphylactic
hypersensitivity to eggs should discuss the vaccine with their HCP, as
alternatives for vaccinating patients with egg allergies are now available.
Advanced age and a history of respiratory illness are not
contraindications for influenza vaccination.
‣ A patient has a tracheostomy tube after reconstructive surgery for
invasive head and neck cancer. What is most important for the nurse to
assess before performing tracheostomy cannula care?
A. Level of consciousness
B. Quality of breath sounds
C. Presence of the gag reflex
D. Tracheostomy cuff pressure -✓✓B. Quality of breath sounds
Rationale:
Before performing tracheostomy care, the nurse will auscultate lung
sounds to determine the presence of secretions. To prevent aspiration,
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‣ A patient whose tracheostomy was inserted 30 minutes ago is
recovering in the postanesthesia recovery unit when the tracheostomy
tube is expelled by coughing. What is the priority action by the nurse?
A. Suction the tracheostomy opening.
B. Maintain the airway with a sterile hemostat.
C. Use an Ambu bag and mask to ventilate the patient.
D. Insert the tracheostomy tube obturator into the stoma. -✓✓B.
Maintain the airway with a sterile hemostat.
Rationale:
As long as the patient is not in acute respiratory distress after dislodging
the tracheostomy tube, the nurse should use a sterile hemostat to
maintain an open airway until a sterile tracheostomy tube can be
reinserted into the tracheal opening. The tracheostomy is an open
surgical wound that has not had time to mature into a stoma. If the
patient is in respiratory distress, the nurse will use an Ambu bag and
mask to ventilate the patient temporarily.
‣ The nurse is reviewing the health history of a patient with laryngeal
cancer. Which finding would the nurse expect?
A. Family history of lung cancer
B. Recent inhalation of noxious fumes
C. Frequent straining of the vocal cords
D. Chronic use of alcohol and tobacco products -✓✓D. Chronic use of
alcohol and tobacco products
,rationale:
Tobacco use causes 85% of head and neck cancers. Excess alcohol use is
another major risk factor. Other risk factors include exposure to the sun,
asbestos, industrial carcinogens, marijuana use, radiation therapy to the
head and neck, and poor oral hygiene.
‣ A patient is being discharged from the emergency department after
being treated for epistaxis. In teaching first aid measures in the event the
epistaxis would recur, what measures should the nurse suggest? (Select
all that apply.)
A. Tilt patient's head backwards.
B. Apply ice compresses to the nose.
C. Tilt head forward while sitting upright.
D. Pinch the entire soft lower portion of the nose.
E. Lying down until 15 minutes after the bleeding ceases -✓✓C. Tilt
head forward while sitting upright.
D. Pinch the entire soft lower portion of the nose.
rationale:
Use simple first aid measures to control nosebleeds. These include: (1)
placing the patient in a sitting position, leaning slightly forward with
head tilted forward and (2) applying direct pressure by squeezing the
entire soft lower portion of the nose (nostrils) together for 5 to 15
minutes. Tilting the head back does not stop the bleeding but allows the
blood to enter the nasopharynx, which could result in aspiration or
nausea or vomiting from swallowing blood. Lying down also will not
decrease the bleeding.
‣ The nurse observes clear nasal drainage in a patient newly admitted
with facial trauma with a nasal fracture. What is the nurse's priority
action?
,A. Test the drainage for the presence of glucose.
B. Suction the nose to maintain airway clearance.
C. Document the findings and continue monitoring.
D. Apply a drip pad and reassure the patient this is normal. -✓✓A. Test
the drainage for the presence of glucose.
Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The
drainage should be tested for the presence of glucose, which would
indicate the presence of CSF. Suctioning should not be done.
Documenting the findings and monitoring are important after notifying
the health care provider. A drip pad may be applied, but the patient
should not be reassured that this is normal.
‣ A patient had an open reduction repair of a bilateral nasal fracture. The
nurse plans to implement an intervention that focuses on both nursing
and medical goals for this patient. Which intervention should the nurse
implement?
A. Apply an external splint to the nose.
B. Insert plastic nasal implant surgically.
C. Humidify the air for mouth breathing.
D. Maintain surgical packing in the nose. -✓✓D. Maintain surgical
packing in the nose.
Rationale:
A goal that is common to nursing and medical management of a patient
after rhinoplasty is to prevent the formation of a septal hematoma and
potential infections resulting from a septal hematoma. Therefore, the
nurse helps to keep the nasal packing in the nose. The packing applies
direct pressure to oozing blood vessels to stop postoperative bleeding. A
medical goal includes realigning the fracture with an external or internal
splint. The nurse helps maintain the airway by humidifying inspired air
, because the nose is unable to do so following surgery because it is
swollen and packed with gauze.
‣ The nurse is scheduled to administer seasonal influenza vaccinations to
the residents of a long-term care facility. What would be a
contraindication to the administration of the vaccine to a resident?
A. Age older than 80 years
B. History of upper respiratory infections
C. Chronic obstructive pulmonary disease (COPD)
D. History of a severe allergic reaction to the vaccine -✓✓D. History of
a severe allergic reaction to the vaccine
Rationale:
Contraindications to vaccination include a history of severe allergic
reactions to previous flu vaccine. Patients with anaphylactic
hypersensitivity to eggs should discuss the vaccine with their HCP, as
alternatives for vaccinating patients with egg allergies are now available.
Advanced age and a history of respiratory illness are not
contraindications for influenza vaccination.
‣ A patient has a tracheostomy tube after reconstructive surgery for
invasive head and neck cancer. What is most important for the nurse to
assess before performing tracheostomy cannula care?
A. Level of consciousness
B. Quality of breath sounds
C. Presence of the gag reflex
D. Tracheostomy cuff pressure -✓✓B. Quality of breath sounds
Rationale:
Before performing tracheostomy care, the nurse will auscultate lung
sounds to determine the presence of secretions. To prevent aspiration,
