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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Perform the confrontation test: The confrontation test is used to assess peripheral vision rather than overall visual acuity. It is not the standard method for measuring visual acuity in routine physical examinations.
B. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches: While this can be useful for assessing near vision, it does not provide a complete assessment of visual acuity, which includes both near and distance vision.
C. Ask the patient to read the print on a handheld Jaeger card: The Jaeger card is specifically used for assessing near vision. While it is useful for determining how well the patient can see up close, it does not assess distance visual acuity, which is typically required in routine examinations for teenagers.
D. Use the Snellen chart positioned 20 feet away from the patient: The Snellen chart is the standard tool for measuring distance visual acuity. It is positioned 20 feet away from the patient to evaluate how well they can see letters of various sizes. This method provides a clear assessment of the patient’s visual acuity for routine physical examinations.
Correct Answer is D
Explanation
A. Bradypnea: Characterized by a regular but abnormally slow respiratory rate, typically fewer than 12 breaths per minute in adults. While the patient’s respiratory rate is 12, the irregular pattern and shallow depth suggest a different pattern rather than simple bradypnea.
B. Agonal respirations: Marked by gasping, labored breaths often seen in severe hypoxia or nearing death. This pattern is typically irregular and associated with brainstem dysfunction, which is not described in this case.
C. Chronic obstructive breathing: Seen in patients with COPD, involving prolonged expiration due to airway obstruction. The patient’s case does not mention an obstructive pattern but rather shallow and irregular respirations.
D. Hypoventilation: Defined by shallow, irregular breathing that leads to inadequate alveolar ventilation, commonly caused by drug overdose, particularly opioids or sedatives. The patient’s presentation of shallow and irregular respirations fits this pattern.
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