The nurse is assessing a patient's nostrils for patency. How should the nurse best perform this assessment?

Insert a nasal tube into each nostril to ensure no blockage is present.

Refer patient to a nasal specialist to ensure there is not any blockage in the nasal cavity.

Press each nostril shut and have the patient sniff to ensure air passage through each nostril.

Have the patient blow their nose into a tissue forcefully.

Answer and Explanation

The Correct Answer is C

A. Insert a nasal tube into each nostril to ensure no blockage is present: Inserting a nasal tube is an invasive procedure that is not necessary for assessing nostril patency. This method can cause discomfort and does not provide a simple or effective assessment of airflow through the nostrils.

B. Refer patient to a nasal specialist to ensure there is not any blockage in the nasal cavity: Referral to a specialist is unnecessary for a basic assessment of nostril patency. The nurse can perform a simple, non-invasive test before considering a referral for further evaluation.

C. Press each nostril shut and have the patient sniff to ensure air passage through each nostril: This method effectively assesses nostril patency. By occluding one nostril at a time, the nurse can evaluate airflow and determine if there is any blockage or obstruction in the nasal passages. It is a quick and straightforward assessment technique.

D. Have the patient blow their nose into a tissue forcefully: Asking the patient to blow their nose can provide information about mucus presence or drainage but does not specifically assess nostril patency. This action may also cause discomfort and is not the best initial assessment for airflow through the nostrils.

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Correct Answer is B

Explanation

A. May show evidence of some clouding of his level of consciousness: While patients who have been in intensive care for an extended period may experience some clouding of consciousness or altered mental status, it is not a universal finding. This option implies a more significant alteration in consciousness than typically expected in a patient transitioning to a medical-surgical unit.

B. Will be oriented to place and person, but the patient may not be certain of the date: This is a common expectation for patients who have been in an intensive care setting for a prolonged period. They may maintain orientation to person and place due to their familiarity with the environment and staff, but they might have difficulty recalling the date due to the stress of hospitalization and changes in routine.

C. Disruptive behavior: While some patients may exhibit changes in behavior after a long stay in intensive care, it is not a standard expectation. Many patients may be more subdued and fatigued rather than disruptive.

D. Will state, "I am so relieved to be out of intensive care": While this response might occur, it is not guaranteed. Patients may have mixed emotions about their transition from intensive care, including anxiety or confusion. Therefore, this statement is not a definitive expectation during the mental status examination.

A. Bronchial breath sounds that are normal in that location. B. Bronchovesicular breath sounds that are normal in that location. C. Normal sounds auscultated over the trachea. D. Vesicular breath sounds that are normal in that location.

Correct Answer is D

Explanation

A. Bronchial breath sounds that are normal in that location: Bronchial breath sounds are high-pitched and louder, with expiration lasting longer than inspiration. They are normally heard over the trachea and not over the posterior lower lobes. If bronchial sounds are heard in the lower lung fields, it may indicate lung consolidation, such as in pneumonia.

B. Bronchovesicular breath sounds that are normal in that location: Bronchovesicular breath sounds are moderate in pitch and intensity, with inspiration and expiration being roughly equal in length. These sounds are typically heard over the major bronchi, near the sternum anteriorly and between the scapulae posteriorly, making them unlikely to be present in the posterior lower lobes.

C. Normal sounds auscultated over the trachea: Breath sounds heard over the trachea are expected to be bronchial, which are loud and high-pitched, with expiration lasting longer than inspiration. The low-pitched, soft sounds described do not match the normal tracheal breath sounds.

D. Vesicular breath sounds that are normal in that location: Vesicular breath sounds are soft and low-pitched, with inspiration lasting longer than expiration. They are the normal breath sounds heard over most of the peripheral lung fields, including the posterior lower lobes, confirming that these findings are normal.

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The nurse is assessing a patient's nostrils for patency. How should the nurse best perform this assessment?

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Naxlex Comprehensive Predictor Exams

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. What should the nurse expect during this patient's tests of cognitive function?

Correct Answer is B

Explanation

When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. How should the nurse interpret these findings?

Correct Answer is D

Explanation

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