Medical-Surgical Nursing Exam 10

EXPLANATION

✔Correct answer:

I'll consume the entire course of medication and then revisit my doctor. This statement indicates an understanding of the importance of completing the full course of antibiotic treatment, even if symptoms improve before the medication is finished. This is essential to prevent the development of antibiotic-resistant bacteria and to ensure that the infection is completely cleared.

✘Incorrect answer options:

I'll take the medication until I feel improvement and then save the remaining pills for any future flare-ups. This approach could lead to incomplete treatment of the infection and the development of antibiotic resistance.

I'll finish the entire course of medication and then get the prescription refilled once. Unnecessary continuation of antibiotics can contribute to antibiotic resistance and may expose the patient to unnecessary side effects.

I'll continue the medication until the symptoms subside, after which I'll reduce the dosage to one pill per day. This approach can also lead to incomplete treatment and the development of antibiotic resistance.

EXPLANATION

✔Correct answer:

Sensations of prickling in the limbs. Hypocalcemia, or low blood calcium levels, can lead to several neurological symptoms due to the increased excitability of nerve tissues. One common symptom is paresthesia, or abnormal sensations in the skin, such as prickling, tingling, or a "pins and needles" sensation. This symptom frequently affects the patient's hands, feet, and sometimes around the mouth.

This symptom, also known as paresthesia, is commonly associated with hypocalcemia. Calcium plays a crucial role in several physiological processes, including muscle contraction, nerve function, and blood clotting. In the context of nerve function, calcium is vital for the conduction of electrical impulses along nerve fibers.

When the level of calcium in the blood is low, it affects the function of the nerves and increases their excitability. This heightened excitability can cause abnormal sensory symptoms, such as feelings of prickling, tingling, or numbness in the limbs. This is because the nerves are sending signals to the brain even when they shouldn't be, leading to these unusual sensations.

Paresthesias most often occur in the extremities (hands, feet) and around the mouth in hypocalcemia. It's important to identify and treat hypocalcemia promptly, not just to alleviate these uncomfortable symptoms, but also because severe hypocalcemia can lead to serious complications such as seizures or cardiac issues.

✘Incorrect answer options:

Diminished reflex responses. Hypocalcemia actually tends to increase reflex responses due to increased neuromuscular irritability. This is the opposite of the diminished reflex responses suggested in this option.

Frequent loose stools. Hypocalcemia does not typically cause frequent loose stools. In contrast, high levels of calcium (hypercalcemia) may slow the movement of the gut and lead to constipation.

Fatigue. While fatigue can be a nonspecific symptom seen in many conditions, it is not typically associated directly with hypocalcemia. Symptoms of hypocalcemia are generally more neurological in nature, such as the paresthesia mentioned in the correct answer.

EXPLANATION

✔Correct answer:

Both the nurse and the patient, as they both have a role to play in the teaching process. The process of setting learning goals for patients should ideally involve both the patient and the nurse. The nurse brings professional knowledge and understanding of the disease process and treatment, while the patient brings personal knowledge about their lifestyle, preferences, and capabilities. This collaborative approach ensures that the goals are not only medically appropriate but also tailored to the patient's individual needs and circumstances, increasing the likelihood of adherence and successful self-management.

✘Incorrect answer options:

The patient, as they are best positioned to identify their own needs and how to address them. While it's true that patients have unique insights into their own needs, they may lack the medical knowledge necessary to set comprehensive and appropriate learning goals for their care.

The patient, nurse, and physician, enabling the patient to participate in care planning with the nurse and physician. While interdisciplinary collaboration is important in overall care planning, the process of setting specific learning goals for patient education often does not require direct physician involvement. However, the nurse should ensure that education plans align with the overall treatment plan established by the patient's healthcare team.

The nurse alone, based on established protocols. While the nurse has the medical knowledge necessary to create an education plan, learning goals should be individualized based on the patient's unique needs and circumstances. Establishing these goals without the patient's input may reduce their effectiveness and the patient's adherence to the plan.

EXPLANATION

✔Correct answer:

An orange, raisin bran with milk, and whole wheat toast spread with butter. This meal is high in dietary fiber, which can help stimulate bowel movements and relieve constipation. Oranges and whole grains such as raisin bran and whole wheat toast are good sources of dietary fiber.

✘Incorrect answer options:

Orange juice, breakfast pastries (such as a doughnut and Danish), and coffee. This meal is high in sugar and low in fiber, which is not ideal for promoting regular bowel movements.

Eggs with bacon, white toast slathered in butter, orange juice, and coffee. This meal is high in fat and low in fiber, which may not promote regular bowel movements and could potentially exacerbate constipation.

Pancakes with maple syrup, sausages, and hot chocolate. This meal is also high in sugar and fat, and low in fiber

EXPLANATION

✔Correct answer:

Young adults aged between 21 and 40. Hodgkin's lymphoma, also known as Hodgkin's disease, has a characteristic bimodal age distribution. It most commonly affects young adults in their 20s and 30s, and then it has a second peak in incidence in people over 55 years of age. The younger age group is more commonly affected, making this the correct choice.

✘Incorrect answer options:

Kids aged between 6 and 12. Hodgkin's disease is relatively rare in this age group.

Mature adults aged between 41 and 50. While Hodgkin's disease can affect adults in this age range, it is not the most common age group affected.

Teenagers aged between 13 and 20. Although Hodgkin's disease can occur in this age group, it is more commonly diagnosed in young adults aged between 21 and 40.

EXPLANATION

✔Correct answer:

Until the nurse encounters resistance, after which it's pulled back 1-2 cm. When suctioning a laryngectomy tube, the nurse typically inserts the catheter until resistance is met, and then it is pulled back slightly (1-2 cm) before beginning suction. This technique is used to avoid trauma to the tracheal mucosa, which can occur if the catheter is inserted too far.

✘Incorrect answer options:

Until the patient starts to cough. While coughing might indicate that the catheter has reached the trachea, this is not a reliable or safe method to determine how far to insert the catheter. It might cause unnecessary discomfort or even harm the patient.

Pressure is applied to the stoma. Applying pressure to the stoma is not a standard procedure in suctioning a laryngectomy tube. It can cause discomfort and potentially damage the stoma.

Approximately 1-2 inches deep. The depth of the catheter insertion will depend on the individual patient's anatomy, not a predetermined measurement. Inserting the catheter 1-2 inches deep without considering the patient's anatomy could lead to injury.

EXPLANATION

✔Correct answer:

Bending down to lace up my shoes should be avoided. After hip replacement surgery, it is recommended to avoid bending at the hip more than 90 degrees because this can lead to dislocation of the new joint. This includes activities such as bending over to tie shoes.

✘Incorrect answer options:

I must refrain from excessive walking for roughly 90 days post-surgery. While it is true that patients should avoid strenuous activities in the immediate post-operative period, walking is encouraged as soon as possible after surgery to promote blood flow and healing. The timeline may vary based on individual cases and surgeon's instructions.

I can bend at the waist or knees as soon as the pain subsides. This statement is incorrect because bending at the hip is usually restricted to avoid dislocation of the new hip joint.

Any chair that offers comfort is suitable for sitting. The type of chair is important after hip replacement surgery. A chair that is too low can cause too much flexion at the hip and potentially lead to dislocation. A firm, straight-backed chair is often recommended.

EXPLANATION

✔Correct answer:

Exhibiting less length compared to the unaffected leg. A common clinical sign of a hip fracture is that the affected leg may appear shorter compared to the unaffected leg. This difference in length is due to the displacement of the fractured bone segments. The patient may also experience pain in the hip, groin, or lower back, and may be unable to bear weight on the affected side.

✘Incorrect answer options:

Maintained in a bent position. While a patient may instinctively hold the affected leg in a bent position due to discomfort, it is not a characteristic sign of a hip fracture.

Kept in an extended straight position. This is not a typical presentation of a hip fracture. Depending on the type and location of the fracture, the leg may not be able to be fully extended due to pain and muscle spasms.

Twisted towards the center of the body (internally rotated). While this can be seen in some hip fractures, it is not the most common presentation. More commonly, the leg may be externally rotated, or turned outward.

EXPLANATION

✔Correct answer:

Fat. During sleep, the body's metabolic processes slow down and the energy requirement decreases. While carbohydrates provide quick energy during waking hours, during sleep, the body primarily uses fat for energy. This is due to fat's high energy density and the body's ability to store larger quantities of fat. It's also worth mentioning that during sleep, the body is in a fasted state, so the use of fat for energy is a way for the body to preserve its glycogen stores.

✘Incorrect answer options:

Water. While essential for numerous bodily functions, water does not provide energy.

Carbohydrate. While carbohydrates are the body's primary energy source during waking hours, during sleep, when the body's energy needs are reduced, it primarily uses stored fat for energy.

Protein. Proteins are typically used for building and repairing tissues and are not the primary source of energy during sleep.

EXPLANATION

✔Correct answer:

The surfaces of the hand and fingers avoid contact. When dressing a burn patient's hand, it is crucial to ensure that the surfaces of the hand and fingers do not contact each other to avoid further damage. This is because blisters and open areas can easily bond to each other if they touch, causing more pain and difficulty when separating the wounds during dressing changes. By keeping the surfaces of the hand and fingers separate, the nurse promotes better healing, limits pain during dressing changes, and encourages greater mobility once the burns have healed.

✘Incorrect answer options:

The dressing material is dampened with sterile normal saline solution. While it is generally beneficial to maintain a moist wound environment, this is not the most crucial aspect when specifically dressing a burn on a patient's hand. Without proper positioning and separation of fingers, even a well-moisturized wound may develop contractures and impair hand function.

The bandage does not contain elastic. Elastic bandages can be used in burn wound care for providing compression, reducing edema, and helping shape the healing tissue, especially in graft areas. The key is to ensure appropriate application to avoid constriction of blood flow.

The hand and fingers are not raised above the heart level. Elevating burned extremities is typically recommended, especially in the acute phase, to minimize swelling. This does not contravene the principles of burn wound care, and in fact, contributes to patient comfort and healing.

EXPLANATION

✔Correct answer:

Confirming that the patient's airway is clear of blockage. The immediate post-operative period in the PACU focuses primarily on ensuring patient safety, which includes maintaining a patent airway and stable vital signs. Anesthesia can affect respiratory function, making it crucial for the nurse to ensure the patient's airway is clear and that the patient is breathing effectively. Any blockage or obstruction could lead to hypoxia or other serious complications.

✘Incorrect answer options:

Checking that the drainage tubes are open and working properly. While important, checking the function of drainage tubes isn't the immediate priority upon a patient's return to the PACU. This task falls under surgical site assessment, which is typically carried out after the patient's overall condition has been stabilized.

Recording the patient's vital signs. Assessing vital signs is very important and should be done immediately after ensuring a patent airway. However, it is not the first priority. Airway always comes first, followed by breathing and circulation (the ABCs of basic life support).

Identifying potential surgical drains. Identifying and assessing surgical drains is an important part of post-operative care, but it's not the initial priority when a patient first arrives in the PACU. This task is typically performed after ensuring the patient has a patent airway and stable vital signs.

EXPLANATION

✔Correct answer:

Postural hypotension. Levodopa, often combined with carbidopa (a drug that helps prevent the breakdown of levodopa before it reaches the brain), is a common treatment for the symptoms of Parkinson's disease. One common side effect of levodopa is postural hypotension, which is a drop in blood pressure that occurs upon standing or when changing position. This can cause dizziness or lightheadedness and increases the risk of falls. The nurse should educate the patient about this possibility and provide guidance on how to change positions slowly to minimize this effect.

✘Incorrect answer options:

Pancytopenia. Pancytopenia, a condition where there's a reduction in the number of red and white blood cells and platelets, is not a common side effect of levodopa. This is more commonly associated with certain chemotherapeutic agents or drugs affecting bone marrow function.

Peptic ulcer. While it's true that levodopa can potentially cause gastrointestinal upset, it is not specifically associated with the development of peptic ulcers. It's important for the patient to take the medication as directed, often with food to minimize gastrointestinal distress.

Dementia. Levodopa treats motor symptoms of Parkinson's disease and does not directly cause dementia. However, it's worth noting that Parkinson's disease itself can be associated with cognitive changes over time, including dementia. Levodopa might not effectively manage these cognitive symptoms.

EXPLANATION

✔Correct answer:

Analyzing the equivalence of the strength exerted by each hand during a grasp. To evaluate muscular power, especially in cases of neurological injury, it is important to test the strength of specific muscle groups and compare between sides. Asking a person to grip with each hand allows the healthcare provider to evaluate and compare the power and strength in each hand, which can help identify weakness or other issues related to the neurological injury.

✘Incorrect answer options:

Requesting that the individual indicate when pressure is exerted on their feet. While this action can help evaluate sensory perception, it is not a direct assessment of muscular power or strength.

Checking for the symmetry in the person's facial expressions. This is a test of cranial nerve function, specifically the facial nerve (cranial nerve VII), and while it can provide valuable information about neurological status, it does not directly assess muscular power in the body.

Studying any unprovoked movements the person may make. Unprovoked movements could indicate a neurological disorder but do not provide a structured evaluation of muscular power or strength.

EXPLANATION

✔Correct answer:

The patient reports a notable improvement in visual acuity. Cataract surgery involves the removal of the natural, clouded lens of the eye and, in most cases, its replacement with an artificial lens. This procedure is typically performed to improve visual acuity, which becomes impaired as a cataract progresses. Therefore, a notable improvement in visual acuity is a positive development and the primary expected outcome of cataract surgery.

✘Incorrect answer options:

The patient can articulate strategies to keep a check on intraocular pressure build-up. While important for ocular health, especially in conditions like glaucoma, monitoring intraocular pressure is not a direct outcome or typical patient responsibility following cataract surgery.

The patient affirms that any previously present infection has been managed. While it's crucial to manage any infections prior to surgery, this is not a direct outcome of cataract surgery. The primary goal of cataract surgery is to improve vision, not to manage infections.

The patient asserts her capability to self-administer injectable pain medication. Pain management post-surgery is important, but the capability to self-administer injectable pain medication is not a typical expectation following cataract surgery. Moreover, post-operative pain from cataract surgery is usually managed with oral or topical medications, not injectables.

EXPLANATION

✔Correct answer:

Retinopathy. Diabetic retinopathy is the most common vision complication associated with diabetes. It occurs when high blood sugar levels cause damage to blood vessels in the retina. These blood vessels can swell and leak, or they can close, stopping blood from passing through. Sometimes abnormal new blood vessels grow on the retina, leading to serious vision problems if not managed.

✘Incorrect answer options:

Glaucoma. Although individuals with diabetes are at a higher risk of developing glaucoma, it is not the most common eye condition associated with diabetes.

Cataracts. Similar to glaucoma, individuals with diabetes are more likely to develop cataracts at an earlier age, but it is not the most common eye complication in diabetes.

Hyperopia. Also known as farsightedness, hyperopia is not specifically associated with diabetes.

EXPLANATION

✔Correct answer:

Two tablets. This is the correct choice because 0.2 grams (g) is equivalent to 200 milligrams (mg). Therefore, if each tablet contains 100 mg, the nurse will need to administer two tablets to equal 200 mg or 0.2g.

✘Incorrect answer options:

Half a tablet. This would only be 50mg, which is significantly less than the prescribed dosage.

Two and a half tablets. This would equal 250mg, which is greater than the prescribed dosage.

Four tablets. This would equal 400mg, which is twice the prescribed dosage.

EXPLANATION

✔Correct answer:

Frequently don't manifest themselves. Hypertension, also known as high blood pressure, is often called the "silent killer" because it usually doesn't have noticeable symptoms. Many people with hypertension feel perfectly fine and are unaware that their blood pressure is high until it is measured during a health examination. Regular monitoring is essential because untreated hypertension can lead to serious complications over time, including heart disease, stroke, and kidney disease.

✘Incorrect answer options:

Indicate a heightened probability of experiencing a stroke. While it's true that hypertension increases the risk of stroke, the symptoms of hypertension themselves do not directly signal an impending stroke. Hypertension is generally asymptomatic.

Only become evident once irreversible damage to the kidneys has taken place. While hypertension can lead to kidney damage, symptoms of hypertension do not typically appear once kidney damage has occurred. Hypertension itself often remains asymptomatic, which is why it is important to regularly monitor blood pressure.

Only present themselves in cases of malignant hypertension. Malignant hypertension, an extremely high blood pressure that rises quickly, can indeed cause noticeable symptoms such as headache, blurred vision, and chest pain. However, this is a severe and rare form of hypertension, and most people with hypertension do not experience these symptoms.

EXPLANATION

✔Correct answer:

Exhibits a gradual increase in food consumption and tolerance. Following gastric resection, a gradual increase in food consumption and tolerance is a positive indicator of satisfactory nutritional intake. This suggests that the patient is able to consume and digest food without discomfort or complications. A measured, gradual increase is preferred, as it allows the patient's body to adjust to the altered digestive system following surgery.

✘Incorrect answer options:

Consumes 2000 mL/day of water. While staying hydrated is important, simply consuming water does not provide all the necessary nutrients for optimal recovery. A balanced diet with adequate protein, carbohydrates, fats, vitamins, and minerals is crucial.

Needs appetite stimulants prescribed. The need for appetite stimulants may indicate that the patient is struggling with appetite or food intake, which does not suggest satisfactory nutritional intake. Ideally, the patient would be able to consume adequate nutrition without the need for appetite stimulants.

Observes a swift increase in weight within a week. A swift increase in weight might not be a positive sign of nutritional recovery. It could suggest fluid retention or other complications. A gradual, steady increase in weight would be a more positive indicator.

EXPLANATION

✔Correct answer:

Propping up the residual limb on a pillow. Elevating a residual limb on a pillow can help decrease swelling and promote venous return due to the principles of gravity and body fluid dynamics.

• Decrease swelling: Edema, or swelling, occurs when fluid accumulates in the tissues. This is common after an injury or surgery like amputation. When the limb is elevated above the level of the heart, gravity assists in pulling this excess fluid away from the peripheral tissues and back toward the central circulation, thereby reducing swelling.
• Promote venous return: Venous return is the flow of blood back to the heart. Gravity assists in venous return when the limb is elevated. By raising the limb above the heart level, the blood can flow more easily back to the heart. This not only aids in reducing swelling but also helps to circulate blood more effectively, which can contribute to better healing of the residual limb.

However, it's crucial to note that prolonged elevation isn't recommended as it can lead to the development of contractures - a condition of shortening and hardening of muscles, tendons, or other tissues leading to deformity and rigidity of joints. This is why the limb is typically elevated only in the immediate post-operative period and then positioned to avoid contracture formation.

✘Incorrect answer options:

Placing the residual limb flat on the bed. While it is important to avoid flexion contractures by not keeping the limb in a bent position, in the immediate postoperative period, slight elevation can help manage edema.

Applying traction to the residual limb. Applying traction is not a standard care practice following amputation and could potentially cause harm to the patient.

Regularly abducting the residual limb. This action is not a standard post-operative practice for a patient who has undergone a leg amputation. It may not be comfortable for the patient and doesn't contribute directly to healing or prevention of post-operative complications.

EXPLANATION

✔Correct answer:

Muscle relaxants. Muscle relaxants are commonly used in the conservative treatment of herniated lumbar discs. They can help to relieve muscle spasms that often accompany this condition, which can contribute to pain and discomfort.

✘Incorrect answer options:

Tranquilizers. Tranquilizers are not typically used in the treatment of a herniated lumbar disk. They are primarily used for managing anxiety and inducing sleep.

Injectable pain relievers. While some forms of pain relief may be used, injectable pain relievers are not typically the first line of treatment for a herniated lumbar disk.

Antibiotics. Antibiotics are used to treat bacterial infections. They would not typically be used in the treatment of a herniated lumbar disk unless an infection was present.

EXPLANATION

✔Correct answer:

Meperidine hydrochloride, commonly referred to as Demerol. For acute pancreatitis, meperidine has often been used as an alternative to morphine because of the belief that morphine could potentially cause spasm of the sphincter of Oddi, a muscular valve that controls the flow of digestive juices from the pancreas and liver into the first part of the small intestine. Spasms of this sphincter could theoretically worsen pancreatitis. However, recent studies have shown morphine to be safe, and it is being used more commonly. That said, meperidine is still a valid option for pain control in acute pancreatitis, particularly in settings where the morphine's safety is still questioned.

✘Incorrect answer options:

Codeine sulfate. Codeine is a milder opioid and may not provide adequate pain relief in a condition like pancreatitis, which is often associated with severe pain.

Cimetidine, also known as Tagamet. Cimetidine is a type of medication called a histamine H2 antagonist, which is used to decrease stomach acid production. While it's beneficial for conditions like peptic ulcer disease or gastroesophageal reflux disease (GERD), it does not provide the level of pain control necessary for pancreatitis.

Morphine sulfate. Morphine sulfate is a strong opioid pain reliever. However, traditionally, there has been concern about using morphine in pancreatitis due to the belief that it could cause spasm of the sphincter of Oddi, potentially exacerbating pancreatitis. Although recent studies have suggested that morphine is safe for use in pancreatitis, meperidine is often chosen if there's any doubt about the potential for sphincter of Oddi spasm.

EXPLANATION

✔Correct answer:

Inadequate peripheral tissue blood flow. The symptoms described – cramping leg pain that subsides with rest (known as claudication), cool and pale feet, and delayed capillary refill – are all signs of peripheral artery disease (PAD), a condition characterized by reduced blood flow to the limbs due to atherosclerotic blockages. This results in inadequate tissue perfusion, leading to the nursing diagnosis of "Inadequate peripheral tissue blood flow."

✘Incorrect answer options:

Hindered physical movement. While pain during movement can restrict mobility, the key issue in this case is the inadequate blood flow causing the pain, not the restriction of movement itself.

Decreased contractility. This typically refers to the heart's ability to contract and pump blood effectively. While PAD can be related to overall cardiovascular health, the symptoms described don't specifically indicate a problem with cardiac contractility.

Damaged skin integrity. Although prolonged inadequate blood flow can lead to skin problems and even ulcers, the symptoms listed don't include any direct evidence of damaged skin integrity.

EXPLANATION

✔Correct answer:

Draining the pouch once it reaches roughly one-third capacity is ideal. It's important to drain an ileostomy pouch before it gets too full, as a pouch that's overly full can lead to leakage and skin irritation. Generally, it's recommended to empty the pouch when it's about one-third full. This statement indicates the client's understanding of proper pouch care.

✘Incorrect answer options:

Wearing a belt is recommended. While some individuals may choose to wear a supportive belt for comfort or security, it's not a universal requirement for ileostomy care. This decision is generally based on personal preference and comfort.

The pouch should be replaced right after my midday meal. There's no specific rule that the pouch should be replaced after a particular meal. The frequency of pouch changes depends on the type of pouching system and individual needs.

A fresh pouch system ought to be implemented daily. Not every ileostomy requires a daily change of the pouch system. Depending on the type of system and individual needs, pouches can often be used for several days before needing to be replaced. This statement may reflect an unnecessary frequency of changes.

EXPLANATION

✔Correct answer:

The extent of the patient's reaction to sharp stimuli in the legs and toes. Spinal anesthesia affects the nerves originating from the spinal cord, leading to numbness in the lower half of the body. As the anesthesia wears off, the patient should regain sensation and motor function in the affected area. Checking for the patient's reaction to sharp stimuli in the legs and toes can help evaluate the return of sensory function, indicating recovery from spinal anesthesia.

✘Incorrect answer options:

The patient's level of awareness and alertness. While it's always important to monitor consciousness, spinal anesthesia specifically affects the lower half of the body and does not typically impact consciousness or alertness.

The speed at which capillaries in the toes refill with blood. Capillary refill is used to assess circulatory status, not the effects of spinal anesthesia.

The frequency and depth of the patient's breathing. While respiratory status is critical to monitor in any postoperative patient, it does not specifically relate to recovery from spinal anesthesia, which primarily affects sensation and movement in the lower body.

EXPLANATION

✔Correct answer:

A sensation of fullness in the inner ear. Meniere's disease is a disorder of the inner ear that can lead to dizzy spells (vertigo), hearing loss, and a ringing sound in the ear (tinnitus). A sensation of fullness or pressure in the ear, often referred to as aural fullness, is a classic symptom that may precede an attack. This sensation is caused by the buildup of excess fluid in the inner ear, which is a key characteristic of Meniere's disease.

✘Incorrect answer options:

An intense headache. While headaches can be associated with many different medical conditions, they are not a classic sign of Meniere's disease.

Nausea. Nausea can be a result of the vertigo experienced during an attack of Meniere's disease, but it is not typically a symptom that precedes an attack.

Anxiety. Anxiety is not a classic sign of Meniere's disease. However, the unpredictable nature of the disease's attacks can lead to feelings of anxiety in some individuals.

EXPLANATION

✔Correct answer:

I aim to take aspirin only on days when the pain seems particularly severe. This statement indicates a need for further instruction on how to properly manage rheumatoid arthritis with aspirin therapy. Aspirin, when used for chronic conditions like rheumatoid arthritis, should be taken consistently as directed by a healthcare provider, not just when symptoms are severe. Regular use can help manage the chronic inflammation characteristic of rheumatoid arthritis and potentially slow disease progression, rather than just relieving acute symptom flare-ups.

✘Incorrect answer options:

Once I mastered taking aspirin with meals, I began purchasing the less costly generic brand. This statement is not a cause for concern. Generic medications contain the same active ingredients as their brand-name counterparts and are equally effective.

I am always on the lookout for symptoms like bleeding gums or blood in my stool. This statement suggests that the patient is aware of the potential side effects of aspirin, which can include gastrointestinal bleeding. Monitoring for these symptoms is an important part of safe aspirin use.

I ensure to take aspirin with food to safeguard my stomach. This statement suggests that the patient understands that taking aspirin with food can help protect the stomach lining and reduce the risk of gastrointestinal side effects.

EXPLANATION

✔Correct answer:

0.53 mL. This can be calculated using a simple ratio: if 15 mg of morphine is equivalent to 1 mL, then 8 mg would be equivalent to how much? Solving this cross-multiplication equation (15/1 = 8/x), we find that x = 0.53 mL (rounded to two decimal places). Therefore, the nurse should administer 0.53 mL to give the correct dose of 8 mg.

✘Incorrect answer options:

0.66 mL. This is incorrect because it represents a miscalculation. Using the correct ratio, 8 mg of morphine is equivalent to 0.53 mL, not 0.66 mL.

0.45 mL. This is incorrect because it represents a miscalculation. Using the correct ratio, 8 mg of morphine is equivalent to 0.53 mL, not 0.45 mL.

0.60 mL. This is incorrect because it represents a miscalculation. Using the correct ratio, 8 mg of morphine is equivalent to 0.53 mL, not 0.60 mL.

EXPLANATION

✔Correct answer:

A deficiency in folate or vitamin B12. Megaloblastic anemia, a type of macrocytic anemia, is usually caused by a deficiency in either folate or vitamin B12. Both of these nutrients are essential for the synthesis of DNA, which is critical for the growth and replication of cells. When either nutrient is deficient, it leads to the production of abnormally large and immature red blood cells known as megaloblasts, which cannot function as effectively as normal red blood cells.

✘Incorrect answer options:

A lack of iron in the body. Iron deficiency typically results in microcytic, not macrocytic anemia. In this type of anemia, the red blood cells are smaller and paler than normal.

Long-standing illness. Chronic diseases can cause anemia, but it's usually normocytic (red blood cells of normal size) rather than macrocytic.

Presence of an infection. While some infections can contribute to anemia, they are typically associated with normocytic anemias, not macrocytic anemias.

EXPLANATION

✔Correct answer:

Potential self-care deficit associated with persistent fatigue. Pneumonia, especially bacterial pneumonia, often leads to symptoms such as fatigue, weakness, and breathlessness, which could limit the patient's ability to perform daily activities and self-care. Therefore, a nursing diagnosis of potential self-care deficit due to persistent fatigue would be most appropriate in this situation.

✘Incorrect answer options:

Decreased fluid volume due to persistent nausea and vomiting. While some patients with pneumonia may experience nausea and vomiting, these symptoms are not as common as fatigue and breathlessness. Moreover, the patient's primary symptom in this scenario is breathlessness, not nausea and vomiting.

Disrupted thought processes owing to insufficient chest pain relief. Though pneumonia can sometimes cause chest pain, there's no indication in the scenario that the patient is experiencing chest pain or disrupted thought processes.

Ineffective cardiopulmonary tissue perfusion resulting from damage to the myocardium. Pneumonia primarily affects the lungs, not the myocardium (the muscle tissue of the heart). While severe cases of pneumonia can affect overall oxygenation and thus indirectly affect heart function, this is not the primary problem in pneumonia.

EXPLANATION

✔Correct answer:

Refrain from holding her breath during any activity. The Valsalva maneuver is performed by forcibly exhaling against a closed airway, often by holding one's breath and straining, as when lifting a heavy weight or during a bowel movement. This can increase intrathoracic and intra-abdominal pressure, leading to a temporary decrease in venous return to the heart and, subsequently, a reduction in cardiac output. When the maneuver is released, a rapid increase in blood pressure can occur. To avoid this, the nurse should instruct the patient not to hold her breath during any activity, including when lifting objects or during bowel movements.

✘Incorrect answer options:

Adopt a side-lying position. While a side-lying position can be comfortable and can assist with certain health conditions, it does not specifically prevent the Valsalva maneuver.

Consume fluids using a straw. Drinking fluids through a straw does not have a direct impact on preventing the Valsalva maneuver. It may be relevant advice for certain conditions, such as following oral surgery, but not in this context.

Limit intake of sodium. Reducing sodium intake is often important for patients with heart disease because it can help manage blood pressure and fluid balance. However, it does not directly prevent the Valsalva maneuver.

EXPLANATION

✔Correct answer:

Take off any previously administered ointment. Before applying nitroglycerin ointment, the nurse should remove any old ointment to prevent overmedication and to ensure the new dose is absorbed effectively. This is especially important with nitroglycerin, which is used to treat angina (chest pain) and can have serious side effects if too much is absorbed.

✘Incorrect answer options:

Ensure the skin where the ointment will be applied is cleaned with alcohol. While it's important to apply the ointment to clean skin, alcohol is not recommended as it can cause irritation and increase absorption of the medication, potentially leading to adverse effects.

Check the patient's allergy history. While it is always important to check a patient's allergy history before administering a new medication, the question asks for an action specifically related to the application of nitroglycerin ointment. The allergy history should already have been checked at the time the medication was prescribed.

Record the patient's pulse rate and rhythm. While monitoring vital signs is important when administering any medication, it is not the first step before applying nitroglycerin ointment. The first step should be to remove any old ointment.

EXPLANATION

✔Correct answer:

Listen attentively in each of the four abdominal quadrants for a total of 5 minutes to confirm the absence of bowel sounds. This practice is essential because bowel sounds can vary considerably and can be intermittent. Therefore, a total of at least 5 minutes should be dedicated to listening to each of the four quadrants before concluding that bowel sounds are absent. This allows for a comprehensive assessment and helps in accurately determining the patient's gastrointestinal function.

✘Incorrect answer options:

Administer a light meal prior to auscultation to stimulate gastrointestinal activity. This is not typically necessary or practical in a clinical setting. Bowel sounds can be auscultated irrespective of recent food intake and providing a meal could potentially interfere with other diagnostic tests or treatments.

Position the patient on their left side to facilitate more effective auscultation. While positioning can sometimes aid in physical assessments, there's no specific need to position a patient on their left side for bowel sound auscultation. The patient is usually supine (lying on their back) during this procedure.

Gently feel the patient's abdomen to identify the optimal location for stethoscope placement. While palpation is a part of the abdominal examination, it's not used to locate the optimal position for the stethoscope during auscultation of bowel sounds. The stethoscope is usually moved in a systematic manner around the four quadrants of the abdomen.

EXPLANATION

✔Correct answer:

Nausea following the consumption of high-fat foods. Cholecystitis, an inflammation of the gallbladder, is often caused by gallstones (cholelithiasis) that block the duct leading out of the gallbladder. When high-fat foods are consumed, the gallbladder contracts to release bile to aid in digestion. If the duct is blocked, this contraction can cause significant discomfort, leading to symptoms such as nausea and vomiting, as well as pain in the upper right or center abdomen. The connection between the consumption of high-fat foods and these symptoms is a characteristic of cholecystitis.

✘Incorrect answer options:

Elevated blood sugar. While diabetes can be a risk factor for gallstones, elevated blood sugar is not a direct symptom of cholecystitis. It is more associated with disorders of the pancreas and insulin regulation.

A high body temperature of 103 F (39.4 C). While cholecystitis can cause a mild fever, a body temperature as high as 103 F is not typically a direct result of cholecystitis. Such a high fever could suggest a more serious infection or other underlying condition.

Dark-colored stools. Dark-colored stools can be a sign of various gastrointestinal issues, but they are not typically associated with cholecystitis. Dark stools are more indicative of issues like upper gastrointestinal bleeding or certain liver conditions where bilirubin processing is affected, changing the color of the stool.

EXPLANATION

✔Correct answer:

Paleness in skin and mucous membranes. Aplastic anemia is a condition in which the body stops producing enough new blood cells. This can lead to deficiencies in oxygen-carrying red blood cells, causing symptoms such as paleness in skin and mucous membranes due to lack of adequate blood supply. If the patient is exhibiting these symptoms, it suggests that the anemia is not being adequately controlled.

✘Incorrect answer options:

Blood pressure reading of 146/90 mm Hg. While this blood pressure reading is considered high (hypertension), it doesn't directly suggest a lack of control over aplastic anemia. However, both conditions need medical attention.

Rapid weight gain. Rapid weight gain isn't typically associated with aplastic anemia. It can be a symptom of many other conditions, including heart failure, kidney disease, or certain endocrine disorders, but it doesn't suggest that aplastic anemia is poorly controlled.

A heart rate of 68 beats per minute with a strong pulse. This is a normal heart rate for an adult. It doesn't indicate a problem with the control of aplastic anemia.

EXPLANATION

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Blood urea nitrogen (BUN) level of 15 mg/dL. A BUN level of 15 mg/dL is within the normal range, which is typically between 7 and 20 mg/dL. In contrast, chronic kidney disease (CKD) is usually associated with elevated BUN levels because the kidneys are less able to eliminate urea, a waste product, from the bloodstream.

✘Incorrect answer options:

Serum creatinine level of 9 mg/dL. An elevated serum creatinine level, such as 9 mg/dL, is expected in CKD because the kidneys are less capable of filtering out creatinine, a waste product from muscle metabolism.

Serum phosphate level of 5.2 mg/dL. In CKD, phosphate levels can increase because the kidneys are unable to excrete phosphate effectively. The normal range for serum phosphate is typically 2.5 to 4.5 mg/dL.

Serum potassium level of 6.0 mEq/L. Hyperkalemia, or elevated potassium levels, is a common finding in CKD due to decreased renal excretion. The normal range for serum potassium is typically 3.5 to 5.0 mEq/L.

EXPLANATION

✔Correct answer:

Swelling of joints, stiffness in the morning, and symmetrical joint movement. Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease that primarily affects the joints. It is characterized by swelling, pain, and stiffness in the joints, particularly after periods of inactivity or upon waking in the morning. The disease typically affects the joints symmetrically, meaning that if one hand or knee has RA, the other usually does too. These are the classic symptoms and signs of RA.

✘Incorrect answer options:

Pain during weight-bearing activities, rash, and mild fever. While joint pain is common in rheumatoid arthritis, it is not typically associated specifically with weight-bearing activities. A rash is not a classic symptom of RA, although some patients might develop rheumatoid nodules or skin manifestations related to associated vasculitis. Fever is not a primary symptom of RA and would typically only occur during severe systemic flare-ups.

Crepitus, formation of Heberden's nodes, and anemia. Crepitus and the formation of Heberden's nodes (bony outgrowths that occur in the joints of the fingers) are more characteristic of osteoarthritis, not rheumatoid arthritis. While people with RA can develop anemia due to chronic disease, it is not one of the main symptoms of RA.

Muscle weakness, malnutrition, and peripheral edema. These symptoms can be seen in many diseases but are not the primary features of rheumatoid arthritis. While RA can cause general weakness and fatigue, it does not typically cause significant muscle weakness unless it has been long standing and untreated. Malnutrition is not a direct symptom of RA, and peripheral edema is not typically a feature of RA unless secondary to medication side effects or related cardiovascular disease.

EXPLANATION

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I'll water down the medicine and sip it through a straw. This is the best practice when taking liquid iron supplements. Diluting the supplement with water or other liquid can prevent teeth discoloration. Using a straw can further help the medicine bypass the teeth and reduce the risk of staining.

✘Incorrect answer options:

I'll monitor my gums for potential bleeding. While it's important to monitor for any unusual bleeding, it's not directly associated with taking liquid iron supplements.

I'll inform the doctor if my stools turn black. Black stools can be a common side effect of iron supplements and are not typically a cause for concern. However, it's always important to communicate any changes to a healthcare provider.

I will take the medication with plenty of calcium-rich dairy foods. This is incorrect as calcium can interfere with the absorption of iron. Iron supplements should be taken on an empty stomach or with a small amount of food if stomach upset occurs.

EXPLANATION

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Ensure the site remains clean and dry. Autograft donor sites should be kept clean and dry to prevent infection and promote healing.

✘Incorrect answer options:

Use a pressure dressing. Pressure dressings are generally not used on autograft donor sites unless there's a specific indication, such as significant bleeding.

Protect it with a dry, occlusive dressing. Occlusive dressings are typically used in the management of certain types of wounds to maintain a moist environment that promotes healing. However, it's not usually the first choice for autograft donor sites as these sites typically heal well with standard wound care.

Apply ice packs every 2 hours. While applying ice can reduce swelling and pain, it's not typically recommended for routine care of autograft donor sites.

EXPLANATION

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These observations are typical for a patient with an ileal conduit. An ileal conduit is a type of urinary diversion where the ureters are connected to a piece of the ileum (part of the small intestine), creating a pathway for urine to exit the body through a stoma. The presence of mucus in the urine is expected in this situation as the mucus is produced by the intestinal tissue used to create the conduit. This is not usually indicative of an infection or a problem with the conduit itself.

✘Incorrect answer options:

The presence of mucus is due to heightened glucose levels in the urine. High glucose levels in the urine (glycosuria) can occur due to conditions like diabetes, but they do not cause mucus production in the urine.

The patient may be in the early stages of a urinary tract infection. While a urinary tract infection can indeed lead to changes in the urine such as cloudiness or an unusual smell, the presence of mucus in the urine of a patient with an ileal conduit is usually normal and not indicative of an infection.

The patient may have a blockage in the urinary tract causing the mucus production. While blockages can cause a variety of symptoms, the presence of mucus in the urine of a patient with an ileal conduit is typically due to the normal secretions of the intestinal tissue used in the conduit, not a blockage.

EXPLANATION

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I can raise the top end of my bed by 4 to 6 inches. Elevating the head of the bed can help prevent gastroesophageal reflux during sleep. This positioning uses gravity to help keep the contents of the stomach from flowing back into the esophagus.

✘Incorrect answer options:

I can lie down on my back without a pillow supporting my head. This position could actually encourage reflux, as it allows stomach acid to flow more easily into the esophagus.

I can sleep on my right side without any pillow support. While side sleeping can sometimes be beneficial for individuals with reflux, research suggests that sleeping on the left side is generally more effective in reducing reflux symptoms than sleeping on the right side.

I can lift the bottom end of my bed by 4 to 6 inches. This position would likely exacerbate gastroesophageal reflux, as it could facilitate the upward flow of stomach acid into the esophagus.

EXPLANATION

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Difficulty in passing urine. Lomotil (diphenoxylate and atropine) is an antidiarrheal medication that slows down the movement of the intestines. Its anticholinergic side effects can include urinary retention or difficulty passing urine. This is a serious side effect and should be reported to the healthcare provider immediately if it occurs.

✘Incorrect answer options:

Dry mouth or throat. While this is a potential side effect of Lomotil due to its anticholinergic properties, it's generally not considered serious or uncommon. It can often be managed by drinking water or sucking on sugarless candies.

Excessive sweating. Excessive sweating is not typically associated with Lomotil. If this symptom occurs, it may be unrelated to the medication and could indicate another medical issue.

Abnormally low blood pressure. While many medications can affect blood pressure, Lomotil is not commonly associated with causing abnormally low blood pressure. If a patient experiences this, it may be due to other factors and should be evaluated by a healthcare provider.

EXPLANATION

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I can perform these exercises in sitting, lying, or standing positions. This statement indicates that the patient has understood the instructions correctly. Kegel exercises, which involve repeated contraction and relaxation of the pelvic floor muscles, can indeed be performed in various positions, including sitting, standing, or lying down. This flexibility allows individuals to incorporate the exercises into their daily routine more easily.

✘Incorrect answer options:

The exercises will likely take a year to show effectiveness. This statement is not accurate. While the exact time frame can vary, most people begin to notice improvements in their symptoms after a few weeks to a few months of regular Kegel exercises.

I'm doing these to increase bladder capacity. This statement is incorrect. Kegel exercises do not increase bladder capacity. They strengthen the pelvic floor muscles, which can help control the release of urine and improve symptoms of stress incontinence.

I ought to do these exercises every night. While it's important to perform Kegel exercises regularly, they should typically be done several times a day, not just at night.

EXPLANATION

✔Correct answer:

Consumption of alcohol and usage of tobacco. The use of alcohol and tobacco, either separately or in combination, is considered the most significant risk factor for the development of laryngeal cancer. Both substances contain numerous carcinogens that can damage the DNA in cells and lead to cancer. Moreover, the combined effect of drinking and smoking is greater than the risk posed by either factor alone.

✘Incorrect answer options:

Belonging to a lower socioeconomic status. While socioeconomic status may influence access to healthcare and health behaviors, it is not a direct cause of laryngeal cancer.

Excessive use of artificial sweeteners. There is no definitive evidence linking the consumption of artificial sweeteners to laryngeal cancer.

Exposure to indoor air pollutants. While certain indoor air pollutants may contribute to respiratory problems and certain types of cancer, tobacco smoke and alcohol consumption are the primary risk factors for laryngeal cancer.

EXPLANATION

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Placement of a laryngectomy tube. In a total laryngectomy, the entire larynx or voice box is removed. This necessitates the creation of a new airway, which is accomplished by forming a stoma or opening in the neck where a laryngectomy tube is inserted. This tube will be the patient's new airway because air can no longer pass through the nose and mouth to the lungs. This is an important postoperative scenario that the patient should be prepared for.

✘Incorrect answer options:

Tracheostomy. Although a tracheostomy is sometimes performed in patients with other types of neck or throat surgeries, in a total laryngectomy, the airway is permanently rerouted to a laryngectomy tube rather than a tracheostomy tube.

Insertion of a gastrostomy tube. While some patients may require a gastrostomy tube for feeding if their ability to swallow is affected, this is not a guaranteed postoperative scenario for all patients undergoing a total laryngectomy.

Endotracheal intubation. This procedure is typically performed during surgery to manage the patient's airway and provide ventilation, but it is not a long-term postoperative scenario in the case of a total laryngectomy.

EXPLANATION

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Cause the smooth muscles in the bronchi to relax. Theophylline, a type of bronchodilator, works by relaxing and opening the air passages in the lungs, which helps improve breathing and reduces symptoms in conditions like COPD.

✘Incorrect answer options:

Increase the absorption of oxygen in the blood. While improved airflow resulting from theophylline usage can enhance oxygen exchange, the medication itself doesn't directly increase the absorption of oxygen in the blood.

Reduce the flexibility of the alveoli. Theophylline does not reduce the flexibility of the alveoli. In fact, medications that do this would likely worsen COPD symptoms by inhibiting the normal function of the lungs.

Decrease the production of secretions in the bronchi. Theophylline does not decrease the production of secretions in the bronchi. Its primary action is to relax the smooth muscles in the bronchi

EXPLANATION

✔Correct answer:

A man who has a permanently placed urinary catheter due to incontinence. Urinary catheters are known to be associated with a high risk of urinary tract infections (UTIs). This is because the catheter can serve as a conduit for bacteria to enter the urinary tract, bypassing the body's normal defenses against infection. The longer a catheter is in place, the greater the risk of developing a UTI. This risk is compounded in those who are incontinent, as fecal bacteria can easily reach the catheter and ascend into the bladder.

✘Incorrect answer options:

A woman who has given birth to two children naturally. While childbirth can lead to some urinary problems such as incontinence due to weakened pelvic floor muscles, it doesn't inherently increase the risk of UTIs.

A woman who manages her diabetes mellitus effectively. Diabetes can increase the risk of UTIs, but this is often related to poor blood sugar control. If a person is managing their diabetes effectively, their risk of developing a UTI would not be significantly higher than the general population.

A child with bowel dysfunction. While bowel dysfunction can potentially increase the risk of UTIs, especially if it involves fecal incontinence, it is less likely to contribute to UTIs than a permanently placed urinary catheter. Proper hygiene and management can often mitigate the risk in these cases.

EXPLANATION

✔Correct answer:

The individual providing the CPR reaches a state of extreme fatigue. CPR is a physically demanding procedure and if the rescuer becomes extremely fatigued to the point of exhaustion, they may need to stop if there is no one else to take over. However, it's always important to try to get someone else to take over or to call for medical assistance as soon as possible.

✘Incorrect answer options:

The victim's family members request a halt to the resuscitation attempts. While the wishes of the family are important, the immediate medical needs of the patient are paramount in an emergency situation. The cessation of CPR based solely on the request of the family, without medical assessment, is not advised.

After performing CPR for half an hour without detecting any pulse in the victim. CPR should be continued until medical professionals arrive and can make an assessment, or until the person begins to show signs of life again. The duration of CPR alone does not determine when to stop.

When it becomes evident that the victim's chances of survival are nil. This is a judgment that should be made by a healthcare professional. Laypeople performing CPR should continue their efforts until professional help arrives.

EXPLANATION

✔Correct answer:

Giving the patient neomycin sulfate in the evening prior to the surgery. Neomycin sulfate is an antibiotic often used to decrease the number of bacteria in the bowel before certain types of surgery, such as gastrointestinal surgery. Its administration can help minimize the risk of postoperative infection.

✘Incorrect answer options:

Suggesting that the patient curtails their physical activities. While patients should avoid strenuous activities right before surgery, light physical activity can help maintain overall health and prepare the body for recovery.

Implementing a nothing-by-mouth (NPO) protocol for 24 hours before the surgery. The standard NPO period is usually about 6 to 8 hours before surgery, not 24 hours, to prevent aspiration during anesthesia. The exact length can vary based on the patient's condition and the type of surgery.

Informing the patient that they will probably be put on total parenteral nutrition post-surgery. While it's possible that a patient may require parenteral nutrition after surgery, it's not a standard part of preoperative care or education. The need for such measures would depend on the individual patient's condition and the specific nature of their surgery.

EXPLANATION

✔Correct answer:

Refraining from sudden head movements. After a scleral buckling procedure for retinal detachment, patients are advised to avoid sudden head movements to prevent further detachment or complications. They should also avoid activities that could increase pressure in the eyes, such as bending over or lifting heavy objects.

✘Incorrect answer options:

Avoiding exposure to excessively bright lights. While it's a common misconception, exposure to bright lights does not directly affect retinal detachment or the recovery process after scleral buckling.

Steering clear of tasks necessitating proficient depth perception. While a patient's vision may be affected initially after surgery, they are not typically advised to avoid all activities requiring depth perception in the long term. This largely depends on individual recovery and should be guided by the healthcare provider.

Implementing daily eye muscle exercises. Eye muscle exercises are not typically recommended following a scleral buckling procedure. The recovery process primarily involves rest and avoiding activities that might strain the eyes or increase intraocular pressure.

EXPLANATION

✔Correct answer:

In a semi-Fowler's position. After a surgical procedure for a deviated nasal septum, the nurse would expect to arrange the patient in a semi-Fowler's position. This is because the semi-Fowler's position, where the patient is lying on their back with the head of the bed elevated to about 30 to 45 degrees, can help reduce swelling and facilitate breathing. In addition, this position can reduce the risk of aspiration, which could occur if the patient experiences nausea or vomiting postoperatively. The semi-Fowler's position also helps to promote drainage from the surgical site, which is crucial in preventing complications such as infection.

✘Incorrect answer options:

Lying on her left side. This position is not typically used after nasal surgery as it may increase pressure on one side of the nose and disrupt the surgical site.

In a prone position. Prone position, where the patient lies on their stomach, is not suitable after nasal surgery as it can lead to increased pressure on the face and surgical site, potentially causing complications.

In a reverse Trendelenburg's position. While this position, with the head higher than the feet, can be used in certain situations to promote lung expansion, it's not specifically recommended for postoperative care of patients who have had surgery for a deviated nasal septum.