MedSurg II - Quiz 2 Ch. 30 & 31

The nurse is preparing to reinforce teaching to a patient scheduled for a laryngectomy due to cancer. Which preoperative teaching review is least necessary for the immediate postoperative period?

• The loss of the ability to breathe through the nose and mouth.

• The process of performing tracheostomy care and suctioning.

• The initial feelings associated with the inability to speak.

• The reason for performing a dietary consult prior to surgery.

The nurse auscultates the lung sounds of a patient with a pneumothorax every 4 hours. Which finding indicates to the nurse that the patient's condition is improving?

• Patient's anxiety is decreasing

• Crackles or wheezes are heard

• Bilateral lung sounds are present

• Symmetry of the chest is noted

The nurse works in a clinic and is performing tuberculosis (TB) screening with the purified protein derivative (PPD). Which option about PPD screening is correct?

• The test is positive if reddened area occurs within 48 to 72 hours

• If a person is allergic, a larger area of induration will appear

• A positive reaction to the test indicates active disease process

• A reddened area without induration is considered negative

The nurse enters the room of a patient who is acutely short of breath. Which action should the nurse take first?

• Assist the patient into Sims position

• Encourage use of pursed-lip breathing

• Ask the patient what caused the dyspnea

• Teach the patient use of accessory muscles

The nurse is providing care for a patient immediately after tonsillectomy. Which action by the nurse should be avoided?

• Maintain the patient in a semi-fowler's position

• Monitor the patient for bleeding and airway maintenance

• Provide the patient with warm tea sweetened with honey

• Place a humidifier and suction equipment in the patient's room

A patient returns to the observation area after outpatient septoplasty for a deviated septum. Which observation will most concern the nurse?

• The patient swallows frequently

• The patient's blood pressure is 136/88 mm Hg

• The patient complains of tenderness in the nasal area

• The patient's moustache dressing has a 2 centimeter area of blood on it

The nurse instructs a patient with a nosebleed to sit up and lean slightly forward. For which reason does the nurse teach the patient to maintain this posture?

• To prevent dizziness or syncope

• To reduce bleeding from the anterior plexus

• To help prevent symptoms of shock due to blood loss

• o avoid unseen blood from being swallowed or aspirated

You are caring for a patient diagnosed with laryngitis, it is important to focus on?

• effective coughing techniques

• Increasing fluids

• Using a cough suppressant at bedtime

• Making sure the patient is resting their voice

The nurse is caring for a patient with a suspected pulmonary embolism (PE). Which diagnostic tests or procedures should the nurse expect to be prescribed for this patient? (Select all that apply - 3). Selecting more than 3 answers may result in receiving zero points. 

• D-Dimer

• Spirometry

• Pulmonary Angiogram

• Ventilation-perfusion lung scan

• Pulmonary Function Test

A patient is admitted to a respiratory unit with a diagnosis of pneumonia. Assessment data reveals the patient to be febrile and experiencing a weak, congested- sounding cough, with moist crackles throughout the lung fields. Based on the data provided, the nurse will focus care on which issue?

• Confusion

• Inadequate oxygen level

• Difficulty with breathing

• Inability to clear the airway