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 A
Explanation
A. VIII: Cranial nerve VIII, also known as the vestibulocochlear nerve, is responsible for transmitting auditory information from the cochlea of the inner ear to the brain, allowing for the perception of sound. It also plays a role in balance by carrying information from the vestibular apparatus regarding head position and movement.
B. VI: Cranial nerve VI, the abducens nerve, controls the lateral rectus muscle, which is responsible for outward eye movement. It does not have any function related to hearing.
C. V: Cranial nerve V, the trigeminal nerve, is primarily responsible for sensation in the face and motor functions such as biting and chewing. It does not conduct nerve impulses related to hearing.
D. VII: Cranial nerve VII, the facial nerve, controls muscles of facial expression and carries taste sensations from the anterior two-thirds of the tongue. While it has some minor roles in the auditory system (such as innervating the stapedius muscle), it is not primarily responsible for conducting nerve impulses related to hearing.
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.
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