Author Question: Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first? a. A ... (Read 26 times)

ishan · **on:** Jun 25, 2018

Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first?

a. A 23-year-old who is complaining of a sore throat and has a muffled voice
b. A 34-year-old who has a scratchy throat and a positive rapid strep antigen test
c. A 55-year-old who is receiving radiation for throat cancer and has severe fatigue
d. A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed

Question 2

Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?

a. Cover stoma with sterile gauze and ventilate through stoma.
b. Attempt to reinsert the tracheostomy tube with the obturator in place.
c. Assess the patient's oxygen saturation and notify the health care provider.
d. Ventilate the patient with a manual bag and face mask until the health care provider arrives.

catron30 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
The patient's clinical manifestation of a muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems.

Answer to Question 2

ANS: B
The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.