MED SURG chapter 27 with 100% correct answers.

1. The nurse teaches a 66-year-old man with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which statement, if made by the patient, indicates further teaching is required? a. "I should avoid using ibuprofen (Motrin) for pain and discomfort." b."It is important for me to take my blood pressure medication every day." "C. I will sit down and pinch the tip of my nose for at least 10 to 15 minutes." d "If I get a nosebleed, I will lie down flat and raise my feet above my heart." d "If I get a nosebleed, I will lie down flat and raise my feet above my heart." 2.The nurse teaches a 20-year-old female patient who is prescribed budesonide (Rhinocort) intranasal spray for seasonal allergic rhinitis. The nurse determines that medication teaching is successful if the patient makes which statement? a "My liver function will be checked with blood tests every 2 to 3 months." b "The medication will decrease the congestion within 3 to 5 minutes after use." c "I may develop a serious infection because the medication reduces my immunity." d "I will use the medication every day of the season whether I have symptoms or not." d "I will use the medication every day of the season whether I have symptoms or not." Brainpower Read More Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:00 / 0:00 Full screen 3.The nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to a 35-year-old female employee. Which question should the nurse ask before administration of this vaccine? a. "Are you allergic to chicken?" b. "Could you be pregnant now?" Correct c. "Did you ever have influenza?" d. "Have you ever had hepatitis B?" b. "Could you be pregnant now?" Correct A 62-year-old male 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 All of the following care tasks are needed by a patient admitted for joint replacement surgery who has had a permanent tracheostomy for over 10 years. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a Suction the tracheostomy. b Check stoma site for skin breakdown. Incorrect c Complete tracheostomy care using sterile technique. d Provide oral care with a toothbrush and tonsil suction tube. Correct d Provide oral care with a toothbrush and tonsil suction tube. Correct The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. What should the nurse do first? a Test the drainage for the presence of glucose. Correct 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. Correct A patient is being discharged from the emergency department after being treated for epistaxis. In teaching the family 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. Correct c Tilt head forward while lying down. d Pinch the entire soft lower portion of the nose. Correct e Partially insert a small gauze pad into the bleeding nostril. b Apply ice compresses to the nose. Correct d Pinch the entire soft lower portion of the nose. Correct When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment? a Patient comfort b Airway patency Correct c Incisional drainage d Blood pressure and heart rate b Airway patency Correct 4.When initially teaching a patient the supraglottic swallow following a radical neck dissection, with which food or fluid should the nurse begin? a Cola Correct b Applesauce c French fries d White grape juice a Cola Correct 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 Hypersensitivity to eggs Correct b Age greater than 80 years c History of upper respiratory infections d Chronic obstructive pulmonary disease (COPD) a Hypersensitivity to eggs Correct Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? a Assessing the need for suctioning b Suctioning the patient's oropharynx Correct c Assessing the patient's swallowing ability d Maintaining appropriate cuff inflation pressure b Suctioning the patient's oropharynx Correct What is the priority nursing assessment in the care of a patient who has a tracheostomy? a Electrolyte levels and daily weights b Assessment of speech and swallowing c Respiratory rate and oxygen saturation Correct d Pain assessment and assessment of mobility c Respiratory rate and oxygen saturation Correct A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when he coughs and expels the tracheostomy tube. How should the nurse respond? a Suction the tracheostomy opening. b Maintain the airway with a sterile hemostat. Correct 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. Correct 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. Correct d Maintain surgical packing in the nose. Correct The school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus (select all that apply)? a Cover the nose when coughing. Correct b Obtain an influenza vaccination. Correct c Stay at home when symptomatic. Correct d Drink non-caffeinated fluids daily. e Obtain antibiotic therapy promptly. a Cover the nose when coughing. Correct b Obtain an influenza vaccination. Correct c Stay at home when symptomatic. Correct The patient seeks relief from the symptoms of an upper respiratory infection (URI) that has lasted for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis? a Coughing b Fever, chills c Dust allergy d Maxillary pain Correct d Maxillary pain Correct The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect? a Nasal packing b Epistaxis balloon c Gastrostomy tube Correct d Peripheral skin care c Gastrostomy tube Correct A patient with a history of tonsillitis complains of difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? a Bilateral erythema of especially large tonsils b Temperature 102.2° F, diaphoresis, and chills c Contraction of neck muscles during inspiration Correct d β-hemolytic streptococcus in the throat culture c Contraction of neck muscles during inspiration Correct The patient has decided to use the voice rehabilitation that offers the best speech quality even though it must be cleaned regularly. The nurse knows that this is what kind of voice rehabilitation? a Electromyograph b Intraoral electrolarynx c Neck type electrolarynx d Transesophageal puncture Correct d Transesophageal puncture Correct a patient was seen in the clinic for an episode of epistaxis , which was controlled by placement of anterior nasal packing. During discharge teaching, the nurse instructs the patient to D. Avoid vigorous nose blowing and strenuous activity D. Avoid vigorous nose blowing and strenuous activity 2. A patient with allergic rhinitis reports severe nasal congestion; sneezing; and watery,itchy eyes and nose at various times of the year. To teach the patient to control these symptoms, the nurse advises the patient to: D keep a diary of when the allergic reaction occurs and what precipitated it. D keep a diary of when the allergic reaction occurs and what precipitated it. A patient is seen at the clinic with fever, muscle aches, sore throat with yellowish exudate, and headache. The nurse anticipates that the collaborate management will include: C a throat culture or rapid strep antigen test. E. Comprehensive history to determine possible etiology D supportive care, including cool, bland liquids. C a throat culture or rapid strep antigen test. E. Comprehensive history to determine possible etiology D supportive care, including cool, bland liquids.