PRACTICE QUESTIONS AND ANSWERS NCLEX RN: 14

PRACTICE QUESTIONS AND ANSWERS NCLEX RN: 14

The RN is planning to teach a 61 yr-old pt w/ a hx of recurrent lung infections. Which instructions does the RN include in the teaching?

1.) Avoiding cardio exercise 2.) Don't go outdoors during the winter season 3.) Limit fluid intake to 500 mL/day 4.) Don't forget to get your flu shot on a yrly basis - 4 => Preventive measure

Explanations:

• = encourage exercise & to be active
• = NO reason NOT to go outside
• = INCREASE fluids to get rid of mucus

A 54 yr-old pt w/ a long hx of cigarette smoking diagnosed w/ laryngeal CA & had a laryngectomy done.The home-care RN instructs the pt's daughter on how to suction the pt's tube. Which observation indicates effective teaching?

1.) Daughter asks mom to take several deep breaths BEFORE stating the suctioning process 2.) Daughter uses a Yankeer to suction the pt's laryngeal tube 3.) Daughter applies suction while both introducing the cath to the tube & out of the tube 4.) Daughter suctions corners of mouth from saliva & then the tube - 1 => Hyperventilation prevents anoxia during suctioning => Hyperoxygenate BEFORE suctioning

Explanations:

• = NO; go in NO suctions, out go in a circular motion or the way out

• = No b/c of cross contamination

-> tube = 1st b/c sterile -> corners of mouth from saliva = 2nd b/c very dirty

This type of cancer is r/t the prolonged used of combined effects of alcohol & tobacco is directly related to development - Laryngeal CA

(Laryngeal CA) _____ are affected 8 times more often than women - Men

(Laryngeal CA) The diagnosis usually occurs between the ages of ____ - 55 & 70

(Laryngeal CA) The medical management includes the following:

=> ___a.)____ therapy in conjunct w/ adjuvant -chemo, or -surgical removal of the larynx = ____b.)____ - a.) Radiation therapy b.) laryngectomy

(Laryngeal CA) What are the 4 other risk factors? - 1.) Vocal straining 2.) Chronic laryngitis 3.) Family predisposition 4.) Industrial exposure to carcinogens

The following S&S are for a.) what type of cancer?

1.) Color changes in mouth or ___b.)___

2.) Cough, ___c.)____, hemoptysis, ___d.)___ => wt. loss, neck pain radiating to the ___e.)__, enlarged cervical nodes => __f.)____ (bad breath) - a.) laryngeal CA b.) Tongue

c.) Dysphagia d.) Dyspnea e.) ear f.) Halitosis

(Laryngeal CA: 3 Nursing care/ Pt. teaching) What is nursing care/ pt. teaching for laryngeal cancer? - 1.)

Provide pre-op teaching:

=> allow pt & family to observe & handle tracheostomy tubes & suctioning equipment => Explain how & why suctioning will take place after surgery => Plan for acceptable communication methods after surgery => Refer pt to speech pathologist

2.) Provide post-op care:

=> Keep call bell/light w/in reach @ ALL times => Ask pt yes/no question whenever possible

3.) Promote Resp. functioning:

=> Assess RR & characteristics Q1-2 hrs => Keep bed in semi-fowlers (45-60 degrees) position @ ALL times => Keep laryngeal airway humidified @ ALL times => Auscultate lung sounds Q2-4 hrs

=> Provide tracheostomy care Q2-4 hrs & prn -> cleaning inner cannula -> suctioning = use a suctioning cath; NOT a yanker (oral suction after seizures) -> applying clean dressing

=> Admin tube feedings as prescribed => Encourage ambulation as early as possible

=> Refer for speech rehabilitation w/ artificial larynx OR to learn esophageal speech

(Laryngeal CA: 3 Nursing care/ Pt. teaching: Providing Pre-op teaching)

1.) __a.)___ pt & family to observe & handle tracheostomy tubes & suctioning equipment

2.) Explain ___b.)____ suctioning will take place after surgery

3.) Plan for acceptable ___c.)____- after surgery

4.) Refer pt to ___d.)____ - a.) Allow b.) How & why suctioning c.) Acceptable communication methods d.) Speech pathologist

(Laryngeal CA: 3 Nursing care/ Pt. teaching: Providing Post-op teaching)

1.) Keep ____a.)___w/in reach @ ALL times

2.) Ask pt __b.)___ question whenever possible - a.) Keep call bell/light within reach b.) Yes/no questions

(Laryngeal CA: 3 Nursing care/ Pt. teaching: Promote Respiratory Functioning)

1.) Assess _a.)___ & characteristics Q__b.)__- hrs

2.) Keep bed in ____c.)____ position @ ALL times

3.) Keep laryngeal airway ___d.)___ @ ALL times