Exam 2: NUR2502/ NUR 2502 (New 2023/ 2024 Update) Multidimensional Care III/ MDC 3 Exam| Questions and Verified Answers| 100% Correct| Grade A- Rasmussen
Exam 2: NUR2502/ NUR 2502 (New 2023/
2024 Update) Multidimensional Care III/
MDC 3 Exam| Questions and Verified
Answers| 100% Correct| Grade ARasmussen
QUESTION
What’s our biggest concern with head and neck cancer?
Answer:
Airway!
Nursing care: Manage potential airway obstructions due to the presence of edema or a tumor.
QUESTION
S/S: Head and Neck Cancer
Answer:
▪ Weight loss
▪ Dysphagia
▪ Pain
▪ Lump in the mouth, throat, or neck
▪ Oral lesions that do not heal in 2 weeks
▪ Persistent, unexplained oral bleeding
▪ Numbness of the mouth, lips, or face
▪ Changes in the fit of dentures
▪ Persistent unilateral ear pain
▪ Hoarseness or change in voice quality
▪ Persistent or recurrent sore throat
▪ SOB
▪ oral leukoplakia
▪ Color changes in mouth or tongue
▪ Burning sensation when drinking citrus or hot liquids
QUESTION
How do you treat head and neck cancer?
Answer:
Radiation or surgery (laryngectomy), pain management with medications
QUESTION
Patient education for radiation
Answer:
skincare
don’t erase the marks
changes in taste
voice SHOULD go back to normal if there’s no surgery
Voice will improve 4-6 weeks post therapy & Rest voice during treatment and use alternative
communication.
QUESTION
Nursing Care: Head and Neck Cancer
Answer:
▪ Manage potential airway obstructions due to the presence of edema or a tumor.
▪ Aspiration precautions
▪ Ventilation and oxygenation.
▪ Monitor arterial blood gases
▪ Assess respiratory rate and depth
▪ Monitor pulse oximetry
▪ Monitor for chemotherapy side effects: N/V
If the patient has had radiation
▪ Consulting speech therapy to assist the patient with communication.
▪ Manage sore throat by implementing pain management strategies (gargling with saline, sucking
on ice, and use of mouthwash and throat sprays).
▪ Instruct the patient to refrain from being in the sun and avoid shaving.
▪ Teach the patient to wear protective clothing and gently clean skin with mild soap daily.
Post-operative management includes:
▪ Maintaining a patent airway by suctioning the patient.
▪ Monitor patient for complications of surgery such as hemorrhage, airway obstruction, wound
breakdown, and possible infection.
▪ Implement nutritional support to meet the patient’s needs. A feeding tube is generally inserted
at the time of surgery to provide nutritional support since oral intake is not possible.
▪ Consult speech and language pathologist to assist patient with communication needs.
Patient and family teaching for diagnosis includes:
▪ Education on performing tracheostomy care to include return demonstration.
▪ Education on the administration of feeding to include return demonstration.
▪ Education on signs and symptoms of infection (fever, chills, redness, drainage at sites) and
when to follow up with the provider.
QUESTION
Nursing Care: Patient has a tracheostomy tube
Answer:
communication
diet – PEG tube
QUESTION
Post-Rhinoplasty patient education
Answer:
Educate the patient not to cough forcefully or strain for the first few days to prevent possible
bleeding.
QUESTION
__ is a condition in which the patient experiences cyclical patterns of breathing
disruption for periods of 10 seconds that occurs at least five times in an hour due to upper airway
obstruction.
▪ These periods of apnea decrease gas exchange, which can lead to an acid-base imbalance.
▪ Patients who suffer from this condition also suffer from excessive daytime sleepiness, inability
to concentrate, and irritability.
▪ The most common cause of the obstruction is the soft palate or tongue.
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A nurse is caring for a client with cystic fibrosis. Which are assessment findings for a client with this disorder?
- GERD
- Steatorrhea
- Thick, sticky mucus
- Recurrent upper respiratory infections
Which intervention promotes comfort and dyspnea management for a client with lung cancer?
Provide supplemental oxygen via nasal cannula or mask
Which of the following is a major diagnostic test for cystic fibrosis?
Sweat chloride test
The nurse is assessing a patient who reports being struck in the face and head several times during the assessment. The nurse observed pink-tinged drainage from the client’s nares. What nursing action provided relevant assessment data?
Place a drop of the drainage on filter paper and look for a yellow ring.
The nurse is providing discharge instructions for a client diagnosed with pneumonia. Which information is the nurse sure to include
Complete antibiotics as prescribed
Rest
Drink fluids
Minimize contact with crowds
A client was recently diagnosed with laryngeal cancer. When the nurse begins taking the client’s history, the client asks, “Did you know that I have cancer?” The appropriate nurse response is
Tell me more about your concerns
A homeless client is being discharged from a long term therapy floor for TB. What referral by the nurse is the most appropriate?
Outpatient public health visiting nurses for direct observation
A nurse is caring for a post-op patient returning to the unit after surgical removal of cancer of the head. Which action should the nurse take initially? SATA
Monitor for airway maintenance
Ensure adequate gas exchange
Assess the client’s hemodynamic status
The nurse teaches a client with asthma to monitor for which problem while exercising
Wheezing from bronchospasm
The nurse is caring for a client one day after receiving radiation therapy for neck cancer. Which finding would the nurse expect after radiation?
Hoarse voice
Anxiety is common among clients who are diagnosed with COPD. Which of the following interventions can assist in reducing a client’s anxiety? SATA
Written plan for dealing with anxiety
Professional counseling
Relaxation techniques
Plan out periods of rest throughout the day
A nurse is providing discharge instructions to a client recently diagnosed with TB. Which statements by the client indicate a correct understanding of the teaching? STA
I will avoid alcoholic beverages while on this treatment plan
I will follow-up with my health care providers regularly
I need to adhere to my medication schedule strictly
A client arrives in the ED with epistaxis (nosebleed). What is the nurse’s priority intervention?
Position the client upright with the head forward
During an admission, the client tells the nurse that she was recently prescribed a new medication called Montelukast. What is the best response to an understanding of the montelukast?
Have you been taking this medication on a scheduled basis?
Montelukast
- Class
- What is it used for?
leukotriene receptor antagonists (LTRAs).
It works by blocking the action of substances in the body that cause the symptoms of asthma and allergic rhinitis
A client who has COPD and asthma is receiving oxygen at 2L per minute. A family member tells the nurse “my mother did not look good so I turned her oxygen up to 7L”. Which of these nursing actions is best?
Decrease oxygen to 2L per minute and assess the client
A client presented to the ED with difficulty breathing. Upon examination the client has pus behind the tonsil and swelling on the right side of her neck. She is diagnosed with a peritonsillar abscess. Which of the following is a treatment priority for this client?
Maintain a patent airway
The nurse is teaching a client about post-rhinoplasty care. Which statement by the client indicates an understanding of the instructions
I will have nasal packing and mustache dressing
OR
I will not cough forcefully or strain for the first few days to prevent possible bleeding.
The nurse knows which of the following is the purpose of montelukast for a client with
Blockers leukotriene receptors to decrease inflammation
The change of shift report has just been completed on the med/surg unit. Which client will the oncoming nurse plan to assess first
Client with cystic fibrosis who has an elevated temperature and a newly increased respiratory rate of 38 breaths/min
The nurse is caring for a client who was recently diagnosed with cystic fibrosis. Which of the following is a treatment option for this disorder?
Chest physiotherapy
A client presented with signs and symptoms that are often associated with lung cancer. Which clinical manifestations does the nurse expect to observe in this client? SATA
Frank hemoptysis
Peripheral edema
Hoarseness
Chest tightness
The nurse is providing education to a client who was prescribed a long acting beta agonist medication. Which statement by the client indicated the client understands
I will take this medication every morning to help prevent an asthma attack
A nursing student is teaching a client about their new diagnosis of pulmonary fibrosis the student would include which of the following in their teaching
Most clients have progressive disease with a life expectancy of less than 5 years
A nurse is caring for a client who has been diagnosed with COPD which of the following would be in a treatment priority
Impaired gas exchange
A nurse is providing education to a client recently diagnosed with pulmonary hypertension. What is the goal of drug therapy for this client?
Reduce the pulmonary pressure to slow cor pulmonale
An 84 year old adult client is diagnosed with rhinosinusitis, the nurse is reviewing the client’s medication history and it’s asking about any over the counter medication symptoms the nurse understands that which of the following medications may be inappropriate for a geriatric client
Antihistamine
The nurse is performing medication teaching for a client with chronic airway limitation. What is the correct sequence for administering inhaled medications
Bronchodilator should be taken at least five minutes before other inhaled drugs
A nurse admits a client form the ED with new onset of dyspnea in a productive cough with suspected pneumonia. The client has an O2 saturation of 96 on 2L of O2 nasal cannula and crackled and bilateral lung bases. Oral temperature 98.9, heart rate of 103 bpm, respiratory rate of 18 breaths per minute. The provider enters the following orders which will the nurse perform first?
Collect sputum sample for culture
The nurse is caring for a 60 year old female client who presented to the emergency room post motor vehicle accident the client was in unrestrained passenger who hit the windshield and has multiple facial laceration and dyspnea. Which is the priority nursing intervention for this client?
Assess maintain the airway
A nurse is providing education to a client regarding diagnosis with sleep apnea which of the following statements by the client indicates an understanding of the teaching?
I should contact the provider if my oxygen level is below 90
The nurse is caring for a client who recently diagnosed with asthma and is providing education on triggers of asthma. Which of the following can potentially trigger the disease process?
Dust pollution, cigarette smoking, exercise, and animal dander
A nurse is caring for a 60 year old client recently diagnosed with neck cancer which of the following assessment finding is most consistent with this diagnoses?
Difficulty swallowing
A 47 year old male client presented to the ER with complaints of nasal and facial pain and bloody discharge he states the symptoms started 3 months ago and has gotten worse. He states that it feels like his nose is blocked up all the time based on these symptoms. Which of the following diagnostic tests would the nurse expect the provider to use?
CT scan of the face
A client with suspected TB is admitted to the hospital along with a private room. Which of the following is appropriate related to isolation precedures?
Negative airflow room with specialty fitted respiratory mask
A nurse is caring for several older clients in the hospital that the nurse identifies as high risk for a healthcare associated pneumonia to reduce this risk what activity should the UAP (unlicensed assistive personnel) do?
Provide oral care every 4 hours
The nurse is assessing a client admitted with status asthmaticus. Initially the nurse heard wheezing in the lungs but now the lungs sounds are inaudible what is the priority intervention?
Activation of the rapid response team to secure an airway
The nurse knows that which of the following tests is needed to confirm a TB diagnosis?
Sputum culture
A nurse is caring for a client who has emphysema, which of the five findings should the nurse expect to assess in the client?
Barrel chest, wheezing, tachypnea, distended jugular veins
A nurse is teaching a 78 year old client about the importance of pneumonia vaccination. Which statement by the client indicated and understanding of the teaching?
I need two different vaccinations to prevent pneumonia
A client has been taking isoniazid (antibiotic) for TB for 3 weeks what information gathered by the public health nurse needs to be reported to the healthcare provider immediately?
Client is drinking 4-6 alcoholic beverages per day
A nurse is caring for a client with end stage emphysema which of the following would be in expected finding?
CO2 – 50 mm hg
In planning care for a client with COPD the nurse acknowledges what statement is true regarding nutritional needs?
COPD can increase metabolism and the client should consume supplements for additional calories and protein
Which of the following is a common problem associated with statistic fibrosis in adults?
Osteoporosis
A client with a recent diagnosis of sinus cancer states that he wants another course of antibiotics because he believes he has another sinus infection. What is the nurse’s best response?
Tell me more about your understanding of sinus cancer symptoms
Which of the statement from a client with seasonal influenza requires additional teaching?
I’m contagious only when symptoms are present
How do you diagnose sleep apnea?
Sleep study
A nursing student is teaching a 72 year old patient about the importance of the pneumonia vaccination. Which teaching requires interventions by the nurse? SATA
A. You will only need one vaccine called pneumonia
B. You will need 2 vaccines to prevent pneumonia
C. If you have had a Prevnar vaccine, then you will not need the Pneumovac vaccine
D. Since you are over 84 years old, only the flu vaccine is suggested
E. You will receive the Prevnar vaccine about a year after Pneumovax vaccine
A, C, D
Overall goal for emphysema and COPD patients
Improve gas exchange
Are emphysema and chronic bronchitis reversible?
No- permanent damage has been made to the respiratory system.
Emphysema – damage to the alveoli
Chronic bronchitis – damage to the bronchioles
Signs and symptoms of emphysema/ COPD? SATA
Tripod position
Barrel chest
Accessory muscle use
Clubbing
SOB
Cyanosis
Dyspnea
How will emphysema/COPD patients be feeling? Patient education? SATA
Anxious – we have to decrease their anxiety (can’t give them sedatives because that will decrease their respirations. We use relaxation techniques, etc).
Progressive relaxation, hypnosis, and biofeedback
What is the priority when assessing a person with facial trauma?
Gas exchange
Signs and Symptoms of airway obstruction
Stridor
SOB
Dyspnea
Signs and symptoms of facial trauma
Edema
Asymmetry
Pain
Leakage of spinal fluid through the ears or nose (can be clear to pink-tinged)
Signs and symptoms of nasal fractures
Bruising
Pain
Nasal deviation/malignment
Crepitus
Blood or clear fluid draining from the nose
Impaired breathing
*Check for cerebral spinal fluid
Causes of epistaxis (nosebleed)
Trauma
Hypertension
Leukemia
Inflammation
Tumor
Decreased humidity
Nose blowing/picking
Chronic cocaine use
Nasal procedure
Signs and symptoms of chronic bronchitis
Blue bloaters – only in the bronchioles
Productive cough
Dyspnea
Tachypnea
Cyanosis
Use of accessory muscles
Pedal edema
Weight gain
JVD
Stridor
Fever
Rhonchi
Wheezing
Complications of COPD
hypoxia
respiratory acidosis
respiratory infections (increased mucus production, inflammation, bronchospasm)
narrowing of the airways
heart failure – cor pulmonale
cardiac dysrhythmias
respiratory failure
decreased quality of life
death
Causes of COPD
cigarette smoking or alpha-one antitrypsin deficiency (genetic)
T/F Cystic fibrosis – chloride utilization deficiency can impact multiple organs
TRUE
What precautions are we using for TB? SATA
Airborne
N95
Negative pressure room
Medications to treat TB
antimicrobials
- isoniazid
- rifampin
- pyrazinamide
- ethambutol
*take long term
How do you diagnose TB?
Sputum culture
*PPD test is NOT for diagnosing, it does NOT mean active exposure
What do antimicrobials do to the body? What is the patient education? SATA
Hepatotoxic
No alcohol
No drugs
Eat a diet with quality protein, iron, vitamins A, B, C, and E and abundant fresh produce
No other use of hepatotoxic medications
__ is a chronic intermittent airway obstruction caused by inflammation of the airway tissue that results in “bronchoconstriction”
Asthma
status asthmaticus
a prolonged, extremely severe, life-threatening asthma attack
A patient comes in with asthma; you listen to their lungs and they have lung sounds; then you lose lung sounds. What does this mean? What do we do next?
Complete airway obstruction
Intubation/Tracheostomy – KEEP AIRWAY OPEN
How do you take asthma medications? SATA
5 minutes apart
Albuterol (bronchodilator) first
Rinse mouth after fluticasone (avoids thrush)
Medications to treat asthma. SATA
Bronchodilators
- Beta2 agonist (SABA) – albuterol, levalbuterol, terbutaline
Corticosteroids
- Fluticasone
- Budesonide
- Mometasone
Leukotriene Modifiers
- Montelukast/Singular
Signs and symptoms of cystic fibrosis
- Recurrent/persistent wheezing
- Recurrent pancreatitis
- Large bulky foul-smelling stools
- Salt loss syndromes
- Respiratory infections
- Dyspnea
- Tachypnea
- Thick mucus
- Barrel chest
- Distended abdomen
- Crackles
- Clubbing
- Decreased pulmonary function
Side effects of long-term steroid use
Osteoporosis
Decreased immunity
Buffalo hump
Thin skin
Weight gain
Hyperglycemia
Peptic ulcer disease
Increased potential for infection
Adrenal insufficiency
Treatment of Cystic Fibrosis
-chest PT, postural drainage
-O2 therapy
-lots of fluid intake (don’t give if they have CHF)
-nutrition management: high calorie/ fat diet
-transplat (lung, double lung, heart/lung)
-positive expiratory pressure
-medications
__ is a common restrictive lung disease that is prevalent in the older adult. The onset is generally slow and results from loss of cellular regulation, which leads to prolonged inflammation of the lung tissue, causing scarring and fibrosis.
Pulmonary fibrosis
*Honeycomb lung
Signs and symptoms of head and neck cancer. SATA
Weight loss
dysphagia
pain
lump in the mouth, throat, or neck
oral lesions that do not heal in 2 weeks
persistent, unexplained oral bleeding
numbness of the mouth, lips, or face
changes in the fit of dentures
persistent unilateral ear pain
hoarseness
persistent sore throat
SOB
color changes
burning sensation when drinking citrus or hot liquids
How do you treat head and neck cancer?
radiation or surgery (laryngectomy)
pain management with medications
Nursing care: Patient has a tracheostomy tube
communication
diet – PEG tube
post rhinoplasty patient education
educate the patient not to cough forcefully or strain for the first few days to prevent possible bleeding
__ is a condition in which the patient experiences cyclical patterns of breathing disruption for periods of 10 seconds that occurs at least 5 times in an hour due to upper airway obstruction.
Sleep apnea
Who is at risk for sleep apnea?
obesity
large uvula
short neck
smoking
enlarged tonsils or adenoids
oropharyngeal edema
treatment of sleep apnea
CPAP (continuous positive airway pressure)
Noninvasive positive-pressure ventilation (NPPV)
BiPAP
APAP
Adenoidectomy
uvulectomy
UPP
tracheostomy
If sleep apnea is untreated, it can lead to __.
Hypoxia
- heart disease
- CVA
- stroke
treatment for pneumonia
- Antibiotics, Oxygen
- Incentive Spirometry
- Early Mobilization
- Airway Clearance & Breathing Techniques
- Steroids
- Fluids
Delegation of Duties
Unable to delegate EAT:
Evaluate
Assess
Teach
What’s the overall goal for a patient with pulmonary hypertension?
- dilate vessels. keeps them patent. allows for proper perfusion and no clot formation
- medications:
calcium channel blockers
endothelin-receptor agonist
natural and synthetic prostacyclin agents
guanylate cyclase stimulators
Signs and symptoms of lung cancer. SATA
dyspnea
fever
use of accessory muscles
change in respiratory pattern
clubbing
weight loss
wheezing
persistent cough
chest pain/tightness
should, arm, or chest wall pain
pleural friction rub
recurring pleural effusion, pneumonia, bronchitis
enlarged lymph nodes
hemoptysis (blood-tinged sputum)
fatigue
hoarseness