NUR 430 Exam Practice Questions All
Solved Correct.
A nurse who is caring for a patient with tracheostomy tube in place has just auscultated rhonchi
bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse
take?
a. encourage increased incentive spirometer
b. encourage the patient to increase oral fluid intake
c. put on sterile gloves and use sterile catheter to suction
d. preoxygenate the patient for 3 minutes before suctioning - Answer c
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which
actions should the nurse include in the plan of care in collaboration with the speech therapist?
a. leave the tracheostomy inner cannula inserted at all times
b. place the decannulation cap in the tube before cuff deflation
c. assess the ability to swallow before using the fenestrated tube
d. inflate the tracheostomy cuff during use of the fenestrated tube - Answer c
Which statement by the patient indicates that the teaching has been effective for a patient
scheduled for radiation therapy of the larynx?
a. i will need to buy a water bottle to carry with me
b. i should not use any lotions on my neck and throat
c. until the radiation is complete, I may have diarrhea
d. alcohol-based mouth washes will help clean oral ulcers - Answer a
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?
a. how much alcohol do you drink in an average week?
b. do you have a family history of head and neck cancer?
c. have you had frequent streptococcal throat infections?
d. do you use antihistamines for upper airway congestion? - Answer a
, a. you will breath through a permanent opening in your neck, but you will not be able to
communicate orally
b. you won't be able to talk right after surgery, but you will be able to speak again after the
tracheostomy tube is removed
c. you won't be able to speak as you used to, but there are artificial voice devices that will give
you the ability to speak normally
d. you will have a permanent opening into your neck, and you will need to have rehabilitation
for some type of voice restoration - Answer d
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?
a. the patient lets the spouse provide tracheostomy care
b. the patient allows the nurse to suction the tracheostomy
c. the patient asks how to clean the tracheostomy stoma and tube
d. the patient uses a communication board to request no visitors - Answer c
The nurse completes discharge instructions for a patient with a total laryngectomy. which
statement by the patient indicates that additional instruction is needed?
a. i must keep the stoma covered with an occlusive dressing at all times
b. i can participate in most of my prior fitness activities except swimming
c. i should wear a medic-alert bracelet that identifies me as a neck breather
d. i need to be sure that i have smoke and carbon monoxide detectors installed - Answer a
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?
a. monitor for bleeding
b. maintain adequate IV fluid intake
c. suction tracheostomy every eight hours
d. keep the patient in semi-fowlers position - Answer d
following a laryngectomy a patient coughs violently during suctioning and dislodges the
tracheostomy tube. which action should the nurse take first?
a. cover the stoma with sterile gauze and ventilate through the stoma
Solved Correct.
A nurse who is caring for a patient with tracheostomy tube in place has just auscultated rhonchi
bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse
take?
a. encourage increased incentive spirometer
b. encourage the patient to increase oral fluid intake
c. put on sterile gloves and use sterile catheter to suction
d. preoxygenate the patient for 3 minutes before suctioning - Answer c
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which
actions should the nurse include in the plan of care in collaboration with the speech therapist?
a. leave the tracheostomy inner cannula inserted at all times
b. place the decannulation cap in the tube before cuff deflation
c. assess the ability to swallow before using the fenestrated tube
d. inflate the tracheostomy cuff during use of the fenestrated tube - Answer c
Which statement by the patient indicates that the teaching has been effective for a patient
scheduled for radiation therapy of the larynx?
a. i will need to buy a water bottle to carry with me
b. i should not use any lotions on my neck and throat
c. until the radiation is complete, I may have diarrhea
d. alcohol-based mouth washes will help clean oral ulcers - Answer a
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?
a. how much alcohol do you drink in an average week?
b. do you have a family history of head and neck cancer?
c. have you had frequent streptococcal throat infections?
d. do you use antihistamines for upper airway congestion? - Answer a
, a. you will breath through a permanent opening in your neck, but you will not be able to
communicate orally
b. you won't be able to talk right after surgery, but you will be able to speak again after the
tracheostomy tube is removed
c. you won't be able to speak as you used to, but there are artificial voice devices that will give
you the ability to speak normally
d. you will have a permanent opening into your neck, and you will need to have rehabilitation
for some type of voice restoration - Answer d
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?
a. the patient lets the spouse provide tracheostomy care
b. the patient allows the nurse to suction the tracheostomy
c. the patient asks how to clean the tracheostomy stoma and tube
d. the patient uses a communication board to request no visitors - Answer c
The nurse completes discharge instructions for a patient with a total laryngectomy. which
statement by the patient indicates that additional instruction is needed?
a. i must keep the stoma covered with an occlusive dressing at all times
b. i can participate in most of my prior fitness activities except swimming
c. i should wear a medic-alert bracelet that identifies me as a neck breather
d. i need to be sure that i have smoke and carbon monoxide detectors installed - Answer a
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?
a. monitor for bleeding
b. maintain adequate IV fluid intake
c. suction tracheostomy every eight hours
d. keep the patient in semi-fowlers position - Answer d
following a laryngectomy a patient coughs violently during suctioning and dislodges the
tracheostomy tube. which action should the nurse take first?
a. cover the stoma with sterile gauze and ventilate through the stoma
