Med/Surg HESI Testbank (700+ Questions) | Latest 2023/24 | Updated & Verified | Guaranteed Success | 253 Pages

The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. The nurse should: 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. When caring for a patient who is 3 hours postoperative laryngectomy, the nurse's highest priority assessment would be: A. Airway patency B. Patient comfort C. Incisional drainage D. Blood pressure and heart rate - A. Airway patency Remember ABCs with prioritization. Airway patency is always the highest priority and is essential for a patient undergoing surgery surrounding the upper respiratory system. When initially teaching a patient the supraglottic swallow following a radical neck dissection, with which of the following foods should the nurse begin? A. Cola B. Applesauce C. French fries D. White grape juice - A. ColaWhen learning the supraglottic swallow, it may be helpful to start with carbonated beverages because the effervescence provides clues about the liquid's position. Thin, watery fluids should be avoided because they are difficult to swallow and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce, would decrease the risk of aspiration, but carbonated beverages are the better choice to start with. The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of 20.Which of the following nursing diagnosis is most appropriate based upon this assessment? A. Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C. Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick secretions