Sem. 2 Upper Respiratory condition

35. The nurse is caring for a client who has recurrent sinusitis. Which consideration could nurse suggest to best decrease the frequency of infections?

Administer an over-the-counter decongestant.

23. A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis?

Apply direct continuous pressure.

25. The nurse is caring for a client experiencing laryngeal trauma. Upon assessment, swelling and bruising is noted to the neck. Which breath sound is anticipated?

Audible stridor without using a stethoscope

20. The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the followng nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Eauscultate lung sounds

15. A nurse is caring for a client following nasal surgery. Which assessment finding best indicates current bleeding?

Frequent swallowing

12. The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

Noisy breathing

30. A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first?

Place a dilator in the stoma to maintain the opening.

3. The emergency department nurse is assessing a client following a motor vehicle accident. The nurse notes facial deformities with swelling and bleeding and a clear drainage coming from the nares. Which diagnostic test is completed to determine whether the clear drainage is cerebrospinal fluid?

Teat fluid with a Dextrostix

1. The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?

a face mask

31. A client recently diagnosed with laryngeal cancer and awaiting a laryngectomy was encouraged to attend a support group prior to surgery. The client asked the nurse about the name of the laryngeal speech method where the client speaks through the wall of the trachea with a device. The nurse is correct to provide teaching on which method?

a tracheoesophageal puncture

17. The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently?

airway patency

7. The nurse is caring for a client following sinus surgery. When assessing the client, the nurse asks him how many fingers are being held up. Why does the nurse assess postoperative visual acuity?

assess damage to the optic nerve

24. The nurse is caring for a client with an upper respiratory disorder. The client states he have a hacky, nonproductive cough, which wakens him during the night. Which over-the- counter medication would the nurse suggest to diminish the cough during the night?

detromethorphan

11. The nurse is caring for a client status after adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect?

edema of the upper airway

2. The nurse is caring for a client status postnasal polypectomy. What would the nurse instruct this client to report?

excessive swallowing

9. The nurse is caring for a client diagnosed with coryza, possibly from the rhinovirus. Vital signs are temperature: 101.2°F, pulse: 72 beats/minute, respirations: 28 breaths/minute, and blood pressure: 112/70 mm Hg. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are course in the bases. Which aftemoon assessment finding suggests the advancement to an infectious process?

temperature rise

16. The nurse in the walk-in clinic obtains a history of an upper respiratory infection with a red, sore throat. The client has been febrile for 3 days. Which nursing assessment should be stressed?

voiding

36. The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?

was chewing ice chips all day long.

13. The nurse is mentoring a new graduate nurse, caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would the nurse respond? Select all that apply.

💊Aspiration 💊Infection 💊Injury to the laryngeal nerve

27. The nurse is providing discharge instructions to a client diagnosed with postoperative tonsillectomy and adenoidectomy. Which discharge instructions would the nurse include? Select all that apply.

💊Avoid carbonated fluids. 💊Gargle with warm saline water. 💊Gradually increase fluids then add soft foods. 💊Apply an ice collar to the neck area.

5. A client visits the physician's office concerned about possible sleep apnea. The client states he lives alone and fears that he will not awaken from sleep. The client states that he has many symptoms which may indicate sleep apnea. Which symptom, stated by the client, is not a symptom of sleep apnea?

I have pressure in the middle of my chest night."

28. The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

Develop an alternate method of communication.

10. The nurse is receiving a client in the postanesthesia care unit (PACU) diagnosed with postoperative tonsillectomy and adenoidectomy. The unlicensed assistive personnel is assisting the client from the stretcher to the bed. The client remains drowsy from anesthesia. In which position would the nurse instruct the unlicensed assistive personnel to place the client?

On a side

6. The nurse is providing suggestions to a client diagnosed with the effects of coryza. Which home remedy is appropriate when combined with medical treatment for pharyngitis?

Salt water gargle

8. The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?

Sudden restlessness

26. A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy?

Tell my wife about it. I do not want to touch it."

4. The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, "Elevate the head of the bed 45°." Which nursing goal is met in this assessment?

The client will have decreased edema.

33. The nurse is caring for a client in a physician's office whose X-ray of the sinus reveals exudate in the maxillary sinus. Which equipment must the nurse have present in the room?

irrigation equipment

19. The nurse is an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would the nurse be sure to include in the workshop? Select all that apply.

💊Industrial polluants 💊tôbacco 💊alcohol

29. The nurse is caring for the client who presents to the clinic with hoarseness for 2 months. Further testing diagnoses laryngeal cancer with the treatment plan of a radical neck dissection. When reinforcing information provided by the physician, which nursing instruction is most correct?

The physician removes lymph nodes, muscles, and tissue

local community group. What should the nurse be sure to include regarding cold tablets 14. The nurse is presenting about upper respiratory infections at an educational event for a containing first-generation antihistamines?

They can cause urinary hesitancy.

tonsillectormy. Why would the nurse ask the client about the use of herbal supplements? 32. The nurse is performing a preoperative assessment on a client who is scheduled for a

They may prolong bleeding.

18. The nurse ls caring for a client in the physician's office with a potential sinus infoction. The physiclan orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, witten by the physlcian, is specifically ordered for this purpose?

Transillumination of the sinus

34. The nurse is caring for a client with a new tracheostomy. Which of the following nursing diagnoses are priorities? Select that apply.

💊Ineffective Airway Clearance related to increased secretions 💊Impaired Gas Exchange related to shallow breathing and anxiousness

21. The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply.

💊Lung sounds of wheezing 💊Arterial blood gases reporting a PaCO2 of 48 and a Pa02 of 84 💊Nasal flaring with abdominal retractions 💊Increased respiratory effort