Chapter 26: Concepts of Care for Patients with Noninfectious Upper Respiratory Problems
A nurse cares for a client who has hypertension that has not responded well to several medications. The client states compliance is not an issue. What action would the nurse take next? a. Assess the client for obstructive sleep apnea. b. Arrange a home sleep apnea test. c. Encourage the client to begin exercising. d. Schedule a polysomnography
A
2. A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets
B,C,D
A nurse teaches a client who has epistaxis and recently had his nasal packing removed. Which statements indicate that the client correctly understood the teaching? (Select all that apply.) a. "I will vigorously blow my nose multiple times eachday." b. "Nasal saline sprays will help to preventrebleeding." c. "I will wait at least 1 month before resuming weight lifting." d. "Ibuprofen will decrease nasal swelling and pain." e. "I will apply a small amount of petroleum jelly to mynares."
B,C,E
A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform first? a. Facial pain b. Vital signs c. Bone displacement d. Airway patency
D
When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? a.Teach the patient about the use of expectorants. b.Use a swab to obtain a sample for a rapid strep antigen test. c.Discuss the need to rinse the mouth out after using any inhalers. d.Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs).
B
A nurse assesses a client who has facial trauma. Which assessment findingsrequire immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin
A,D
A nurse is teaching a community group about the long-term effects of untreated sleep apnea. What information does the nurse include? (Select all that apply.) a. Hypertension b. Stroke c. Weight gain d. Diabetes e. Cognitive deficits f. Pulmonary disease
A,B,C,D,E,F
A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Tuck the chin down when swallowing c. Breath slowly and deeply while swallowing d. keep the head very still and straight when swallowing
B
A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask?a."How much alcohol do you drink in an average week?" b."Do you have a family history of head or neck cancer?" c."Have you had frequent streptococcal throat infections?" d."Do you use antihistamines for upper airway congestion?"
A
1. The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? a."I must keep the stoma covered with an occlusive dressing at all times." b."I can participate in most of my prior fitness activities except swimming." c."I should wear a Medic-Alert bracelet that identifies me as a neck breather." d."I need to be sure that I have smoke and carbon monoxide detectors installed
A
11. While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? a. Contact the provider and prepare for intubation b. Administer prescribed albuterol nebulizer therapy c. Place the client in high fowlers position d. ask the client to preform deep breathing exercises
A
15. 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
A
18. The nurse is caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the most immediate action by the nurse? a.The oxygen saturation is 89%. b.The nose appears red and swollen. c.The patient's temperature is 100.1° F (37.8° C). d.The patient complains of level 8 (0 to 10 scale) pain.
A
19. After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider?a.Clear nasal drainage b.Complaint of nasal pain c.Bilateral nose swelling and bruising d.Inability to breathe through the nose
A
13. A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first? a. Assess the clients pain level. b. Keep the clients head elevated. c. Teach the client about the causes of nasal bleeding. d. Make sure the string in taped to the clients cheek
D
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant. b. A 42-year-old man with gastroesophageal reflux disease. c. A 55-year-old woman who is 50 lb (23 kg) overweight. d. A 73-year-old man with type 2 diabetes mellitus.
C
6. The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated? a.Use a manometer to ensure cuff pressure is at an appropriate level. b.Check the amount of cuff pressure ordered by the health care provider. c.Suction the patient first with a fenestrated inner cannula to clear secretions. d.Insert the decannulation plug before the nonfenestrated inner cannula is remove
A
7. A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first? a. Initiate Standard Precautions. b. Apply direct pressure. c. Sit the client upright. d. Loosely pack the nares with gauze.
A
7. Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx? a."I will need to buy a water bottle to carry with me." b."I should not use any lotions on my neck and throat." c."Until the radiation is complete, I may have diarrhea." d."Alcohol-based mouthwashes will help clean oral ulcers."
A
8. A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first? a. Ask the client to gargle with mouthwash containing lidocaine. b. Administer prescribed intravenous pain medications. c. Explain that soreness is normal and will improve in a couple days. d. Assess the clients neck for redness and swelling
A
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next? a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck.
A
3. A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. swollen chin
A,D
Which action should the nurse take first when a patient develops a nosebleed?a.Pinch the lower portion of the nose for 10 minutes. b.Pack the affected nare tightly with an epistaxis balloon. c.Obtain silver nitrate that will be needed for cauterization. d.Apply ice compresses over the patient's nose and cheeks.
A
1. A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.
A,B,C,D
5. A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. You will need to cut the wires if you start vomiting. b. Eat six soft or liquid meals each day while recovering. c. Irrigate your mouth every 2 hours to prevent infection. d. Sleep in a semi-Fowlers position after the surgery. e. Gargle with mouthwash that contains Benadryl once a day.
A,B,C,D
A nurse assesses a client who is 6 hours postsurgery for a nasal fracture and has nasal packing in place. What actions would the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequentswallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.
A,B,C,D
A nurse teaches a client who is being discharged after a jaw wiring for a mandibular fracture. Which statements would the nurse include in this patient's teaching? (Select all that apply.) a. "You will need to cut the wires if you start vomiting." b. "Eat six soft or liquid meals each day while recovering." c. "Use a Waterpik for dental hygiene until you can brush again. d. "Sleep in a semi-Fowler position after the surgery." e. "Gargle with mouthwash that contains hydrogen peroxide once a day."
A,B,C,D
The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)? a.A 76-year-old nursing home resident b.A 36-year-old female patient who is pregnant c.A 42-year-old patient who has a 15 pack-year smoking history d.A 30-year-old patient who takes corticosteroids for rheumatoid arthritis e.A 24-year-old patient who has allergies to penicillin and cephalosporins
A,B,D
The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A, B, C, D].) a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage.
A,B,D,C
A nurse assesses a client who is at risk for neck cancer. Which symptoms would the nurse assess for? (Select all that apply.) a. Oral mucosa is gray or dark brown b. Pain when drinking grapefruit juice c. Persistent weight gain over the past 2 months d. Oral lesions that are over 2 weeks old e. Changes in the patient's voice quality
A,B,D,E
6. A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.) a. A 24-year-old with a traumatic brain injury b. A 36-year-old who fractured his left femur c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident
A,C,D,E
A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for airway loss related to aspirated oral and nasopharyngeal secretions? (Select all thatapply.) a. A 24 year old with a traumatic brain injury b. A 36 year old who fractured his left femur c. A 58 year old getting radiation therapy d. A 66 year old who is a quadriplegic e. An 80-year-old who is aphasic
A,C,D,E
The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)?a.Decongestants can be used to relieve swelling. b.Blowing the nose should be avoided to decrease the nosebleed risk. c.Taking a hot shower will increase sinus drainage and decrease pain. d.Saline nasal spray can be made at home and used to wash out secretions. You will be more comfortable if you keep your head in an upright position
A,C,D,E
While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. What action would the nurse take first? a. Contact the primary health care provider and prepare for intubation. b. Administer prescribed albuterol nebulizer therapy. c. Place the client in high-Fowler position. d. Ask the client to perform deep-breathing exercises.
ANs A
5. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant b. A 42-year-old man with gastroesophageal reflux disease c. A 55-year-old woman who is 50 pounds overweight d. A 73-year-old man with type 2 diabetes mellitus
Ans C
A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met? a. Client reports pain is controlled satisfactorily with analgesic regime. b. Client does not have foul odor to the breath or beefy red mucusmembranes. c. Client is able to swallow own secretions without drooling. d. Client's vital signs are within normal parameters.
Ans C
14. A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this clients teaching? a. Add peppermint oil to the humidifier to relax the airway. b. Make sure you clean the humidifier to prevent infection. c. Keep the humidifier filled with water at all times. d. Use the humidifier when you sleep, even during daytime naps.
B
16. The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider? a.Fever of 100.4° F (38° C) b.Diffuse crackles in the lungs c.Sore throat and frequent cough d.Myalgia and persistent headache
B
17. Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? a.Assess the patient's risk for aspiration. b.Suction the tracheostomy when needed. c.Teach the patient about self-care of the tracheostomy. d.Determine the need for replacement of the tracheostomy tube
B
6. After teaching a client who is prescribed voice rest therapy for vocal cord polyps, a nurse assesses the client's understanding. Which statement indicates the client needs further teaching? a. I will stay away from smokers to minimize inhalation of secondhand smoke. b. When I speak, I will whisper rather than use a normal tone of voice c. For the next several weeks, I will not lift more than 10 pounds d. I will drink at least three quarts of water each day to stay hydrated.
B
A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond? a. "I will consult the speech therapist to ensure you are swallowing properly." b. "This is normal after surgery. What types of food do you like to eat?" c. "I will ask the dietitian to change the consistency of the food in your diet." d. "Replacement of protein, calories, and water is very important aftersurgery."
B
A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond? a. I will consult the speech therapist to ensure you are swallowing properly. b. This is normal after surgery. What types of food do you like to eat? c. I will ask the dietitian to change the consistency of the food in your diet. d. Replacement of protein, calories, and water is very important after surgery.
B
A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement would the nurse include in this patient's teaching? a. "Add peppermint oil to the humidifier to relax the airway." b. "Make sure you clean the humidifier to prevent infection." c. "Keep the humidifier filled with water at all times." d. "Use the humidifier when you sleep, even during daytime naps."
B
A nurse teaches a client who had a supraglottic laryngectomy. Which technique would the nurse teach the client to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Swallow twice while bearing down. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing.
B
The nurse is teaching a client with obstructive sleep apnea (OSA) about the prescribed CPAP. What information does the nurse include? (Select all that apply.) a. Insurance will cover the cost if you wear it at least 4 hours a day. b. Once the delivery mask is adjusted, do not loosen the straps. c. The CPAP provides pressure that holds your upper airways open. d. You need to clean the mask at least once a week to prevent infection. e. The humidification increases the risk of fungal infections. f. Be patient when first using the system, it can be frustrating at first.
B,C,E,F
4. A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.) a. A 32-year-old who had a radical neck dissection 6 hours ago b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago c. A 55-year-old who needs discharge teaching after a laryngectomy d. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement
B,E
. The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? a."I can take acetaminophen (Tylenol) to treat my discomfort." b."I will drink lots of juices and other fluids to stay well hydrated." c."I can use my nasal decongestant spray until the congestion is all gone." d."I will watch for changes in nasal secretions or the sputum that I cough up."
C
4. A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a.Encourage increased incentive spirometer use. b.Encourage the patient to increase oral fluid intake. c.Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning.
C
A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme dry mouth. What action by the nurse is most appropriate? a. Ask the client to gargle with mouthwash containing lidocaine. b. Administer IV fluid boluses every 2 hours. c. Explain that xerostomia may be a permanent side effect. d. Assess the client's neck for redness and swelling.
C
A nurse cares for a client who is scheduled for a total laryngectomy. What action would the nurse take prior to surgery? a. Assess airway patency, breathing, and circulation. b. Administer prescribed intravenous pain medication. c. Assist the client to choose a communication method. d. Ambulate the client in the hallway to assess gait.
C
A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, How will this medication help me? How should the nurse respond? a. This medication will treat your sleep apnea. b. This sedative will help you to sleep at night. c. This medication will promote daytime wakefulness. d. This analgesic will increase comfort while you sleep.
C
A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving? a.The patient lets the spouse provide tracheostomy care. b.The patient allows the nurse to suction the tracheostomy. c.The patient asks how to clean the tracheostomy stoma and tube. d.The patient uses a communication board to request "No Visitors."
C
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist?a.Leave the tracheostomy inner cannula inserted at all times. b.Place the decannulation cap in the tube before cuff deflation. c.Assess the ability to swallow before using the fenestrated tube. d.Inflate the tracheostomy cuff during use of the fenestrated tube
C
10. A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery? a. Assess airway patency, breathing, and circulation. b. Adminster prescribed intravenous pain medication c. Assist the client to choose a communication method d. ambulate the client in the hallway a to assess gait
C.
1. The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful? a."I can take 800 mg ibuprofen for pain control." b."I will safely remove and reapply nasal packing daily." c."My nose will look normal after 24 hours when the swelling goes away." d."I will keep my head elevated for 48 hours to minimize swelling and pain."
D
13. A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action? a.Monitor for bleeding. b.Maintain adequate IV fluid intake. c.Suction tracheostomy every eight hours. d.Keep the patient in semi-Fowler's position
D
2. The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? a.Hand washing is the primary way to prevent spreading the condition to others. b.Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions. c.Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. d.Identification and avoidance of environmental triggers are the best way to avoid symptoms
D
20. A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being "stuck up my nose" and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first? a.Notify the clinic health care provider. b.Obtain aerobic culture specimens of the drainage. c.Ask the patient about how the cotton got into the nose. d.Have the patient occlude the left nare and blow the nose.
D
3. A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first? a. Contact the provider for a prescription for sleep medication. b. Tell the client not to drink beverages with caffeine before bed. c. Educate the client to sleep upright in a reclining chair. d. Ask the client if he or she has ever been evaluated for sleep apnea.
D
4. 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.
D
9. A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the best response by the nurse? a."You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." b."You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." c."You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally." d."You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration."
D
A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first? a. Assess the client's pain level. b. Keep the client's head elevated. c. Teach the client about the causes of nasal bleeding. d. Assess the client's airway.
D
The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care?a.Avoid giving patient warm liquids to drink. b.Assess patient for allergies to penicillin antibiotics. c.Teach the patient about the need to sleep in a warm, dry environment. d.Teach patient to "swish and swallow" prescribed oral nystatin (Mycostatin)
D