MDC 3 Rasmussen Module 4 Assessment Respiratory/ Upper Respiratory D/Os
The nurse is caring for a patient with a pulmonary disorder. What observation by the nurse is indicative of a very late symptom of hypoxia? a.Cyanosis b.Dyspnea c.Restlessness d.Confusion
a.Cyanosis
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°." This assists in meeting which nursing goal? a.The client will have decreased edema. b.The client will have increased tissue perfusion. c.The client will have decreased pain. d.The client will remain alert and oriented.
a.The client will have decreased edema.
What is the difference between respiration and ventilation? a.Ventilation is the movement of air in and out of the respiratory tract. b.Ventilation is the exchange of gases in the lung. c.Ventilation is the process of gas exchange. d.Ventilation is the process of getting oxygen to the cells.
a.Ventilation is the movement of air in and out of the respiratory tract.
The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as a.pleural friction rub. b.crackles. c.sibilant wheezes. d.sonorous wheezes.
a.pleural friction rub.
The nurse is preparing a client with possible pulmonary embolism for a CT scan with contrast. Prior to the scan, which of these assessment questions is essential for the nurse to ask? a."Do you take supplements containing vitamin K?" b."Did you take metformin today?" c."Are you allergic to peanuts?" d."Have you had shortness of breath recently?"
b."Did you take metformin today?"
A client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure? a."I hope I can learn esophageal speech." b."I will have to take special care not to aspirate while eating." c."I won't be able to breathe through my nose anymore." d."It is hard to believe that I will never hear my own voice again."
b."I will have to take special care not to aspirate while eating."
A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube? a."The ET tube will remain in place for at least a day postsurgery." b."The ET tube will maintain your airway while you're under anesthesia." c."The ET tube will be inserted through an opening in your trachea." d."The ET tube will be connected to a negative-pressure ventilator."
b."The ET tube will maintain your airway while you're under anesthesia."
The nurse at an employee wellness clinic is meeting with a client who reports voice hoarseness for more than 2 weeks. To determine if the client may have symptoms of early laryngeal cancer, the next question the nurse should ask is, "Do you have a.difficulty swallowing foods" b.a persistent cough or sore throat" c.a foul odor to your breath" d.trouble with your breathing"
b.a persistent cough or sore throat"
Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy? a.deficient knowledge b.impaired verbal communication c.risk for chronic low self-esteem d.risk for infection
b.impaired verbal communication
A late complication of radiation therapy is a.pain. b.laryngeal necrosis. c.dysphasia. d.xerostomia.
b.laryngeal necrosis.
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: a.hold his nose while bending forward at the waist. b.sit upright, leaning slightly forward. c.blow his nose and then put lateral pressure on his nose. d.lie supine with his neck extended.
b.sit upright, leaning slightly forward.
The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify? a."My study is scheduled for 10 AM, several hours after I eat." b. "I brought comfortable clothes and shoes for the test." c. "I will breathe in through my mouth and out through my nose." d."I am ordered a bronchodilator to note lung improvement following use."
c. "I will breathe in through my mouth and out through my nose."
A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What primary assessment will the nurse make while preparing the client for a computed tomography (CT) scan? a."Do you have any metal anywhere in your body?" b."Do you have diabetes?" c."Are you allergic to iodine or shellfish?" d."Do you drink alcohol regularly?"
c."Are you allergic to iodine or shellfish?"
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? a."Limit the amount of protein in the diet." b."Oral intake of fluids should be limited for 1 week only." c."Family members should continue to talk to the client." d."Clean the tracheostomy tube with alcohol and water."
c."Family members should continue to talk to the client."
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: a.The voice was spared and a tracheostomy would be in place until the airway was established. b.One vocal cord was removed along with a portion of the larynx. c.A portion of the vocal cord was removed. d.A permanent tracheal stoma would be necessary.
d.A permanent tracheal stoma would be necessary.
Which is a true statement regarding air pressure variances? a.The diaphragm relaxes during inspiration. b.The thoracic cavity becomes smaller during inspiration. c.Air flows from a region of lower pressure to a region of higher pressure during inspiration. d.Air is drawn through the trachea and bronchi into the alveoli during inspiration.
d.Air is drawn through the trachea and bronchi into the alveoli during inspiration.
The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care? a.Apply pressure to the convex of the nose. b.Position the patient in the side-lying position. c.Restrict fluid intake. d.Apply an ice pack.
d.Apply an ice pack.
The nurse is working in an urgent care clinic where four clients are waiting to be seen. Which client needs to be evaluated first by the nurse? a.Client who is short of breath after walking up two flights of stairs b.Client with a 10 mm area of redness on the arm after receiving purified protein derivative (Mantoux) skin test c.Client with sore throat and fever of 102.2°F (39°C) oral d.Client who is speaking in three-word sentences and has an SpO2 of 90%
d.Client who is speaking in three-word sentences and has an SpO2 of 90%
What finding by the nurse may indicate that the client has chronic hypoxia? a.Cyanosis b.Peripheral edema c.Crackles d.Clubbing of the fingers
d.Clubbing of the fingers
The nurse is caring for a client with heart failure and acute kidney injury. For which of these breath sounds will the nurse assess? a.Crackles b.Rhonchi c.Pleural friction rub d.Wheeze
a.Crackles
Which assessment finding in the client with exacerbation of emphysema requires intervention by the nurse? a.Barrel-shaped chest b.Bronchial breath sounds heard at the bases c.Hyperresonance to percussion of the chest d.Ribs lying horizontal
b.Bronchial breath sounds heard at the bases
The nurse auscultates crackles in a patient with a respiratory disorder. With what disorder would crackles be commonly heard? a.Asthma b.Bronchospasm c.Collapsed alveoli d.Pulmonary fibrosis
c.Collapsed alveoli
Which term will the nurse use to document the inability of a client to breathe easily unless positioned upright? a.Hypoxemia b.Dyspnea c.Hemoptysis d.Orthopnea
d.Orthopnea
A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client? a."Gargle with a warm salt solution." b."Decrease oral intake if increased swallowing occurs." c."You are allowed to have hot tea or coffee." d."You may have a sore throat for 1 week."
a."Gargle with a warm salt solution."
The nurse is providing education on preventing pulmonary disorders at a community health fair. Which of these groups does the nurse target? Select all that apply. a.Bakers b.Coal miners c.Electricians d.Furniture refinishers e.Plumbers f.Potters
a.Bakers b.Coal miners d.Furniture refinishers f.Potters
High or increased compliance occurs in which disease process? a.Emphysema b.Pneumothorax c.ARDS d.Pleural effusion
a.Emphysema
The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first? a.Pulse oximetry b.Arterial blood gases c.Pulmonary function test d.Chest x-ray
a.Pulse oximetry
The nurse is caring for a client who is to undergo a thoracentesis. In preparation for the procedure, the nurse places the client in which position? a.Sitting on the edge of the bed b.Lateral recumbent c.Prone d.Supine
a.Sitting on the edge of the bed
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? a.A client sitting in a chair after prolonged bed rest b.A client on a ventilator with PEEP c.A client experiencing hypothermia d.A client receiving oxygen therapy via Venturi mask
c.A client experiencing hypothermia
The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised? a.Obtain vital signs. b.Assess capillary refill. c.Monitor heart rhythm. d.Auscultate lung sounds.
d.Auscultate lung sounds.
A client has undergone a laryngectomy. The nurse notes evidence of wound breakdown. The nurse understands that the client is at a high risk for developing a.Dehydration b.Pulmonary embolism c.Pneumonia d.Carotid artery hemorrhage
d.Carotid artery hemorrhage
The clinical finding of pink, frothy sputum may be an indication of which condition? a.Bronchiectasis b.Lung abscess c.Infection d.Pulmonary edema
d.Pulmonary edema
A client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response? a."Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe." b."Because your body isn't getting enough oxygen you wake up and breathe." c."Your tongue may be blocking your throat, and you wake up because you are choking." d."You really aren't waking up that often. It just feels that way."
a."Carbon dioxide builds up while you are not breathing which stimulates your body to wake up and breathe."
A client has received packing for a posterior nosebleed. In reviewing the client's prescriptions, which of these does the nurse question? a."Ibuprofen 800 mg every 8 hours as needed for pain." b."Elevate the head of the bed 45 to 60 degrees." c."Provide humidified air." d."Have suction available at the bedside."
a."Ibuprofen 800 mg every 8 hours as needed for pain."
When reviewing discharge care with the client who has had a laryngectomy, the client states the morphine doesn't work well because he still has shooting pain in the incisional area. Which of these does the nurse suggest be prescribed? a.A nonsteroidal anti-inflammatory drug b.Lorazepam c.An increase in the morphine dose d.Acetaminophen
a.A nonsteroidal anti-inflammatory drug
Which of the following is the most effective treatment for obstructive sleep apnea (OSA)? a.Continuous positive airway pressure (CPAP) b.Mechanical ventilation c.Bilevel positive airway pressure (BiPAP) d.Oxygen by nasal cannula
a.Continuous positive airway pressure (CPAP)
A client is admitted to the medical floor with a new diagnosis of lung cancer. How will the nurse initially assist the client in managing the anxiety associated with the new diagnosis? a.Encourage the client to ask questions and verbalize concerns. b.Provide privacy for the client to be alone to deal with his or her own feelings. c.Medicate the client with diazepam for anxiety every 8 hours. d.Provide journals about cancer treatment.
a.Encourage the client to ask questions and verbalize concerns.
The nurse is caring for a client who has just had radical neck surgery and is receiving mechanical ventilation. Which of these assessments takes priority? a.Observing the dressing for bright-red blood b.Monitoring for decreased level of consciousness c.Evaluating the outcome of pain management strategies d.Analyzing trends of urine output since surgery
a.Observing the dressing for bright-red blood
The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include? a."A speech therapist will evaluate you and recommend a system of communication after surgery." b."You can use writing or a communication board to communicate." c. "After surgery you will have a sore throat, but you will be able to speak." d."After surgery you will have to use an electric larynx to communicate."
b."You can use writing or a communication board to communicate."
The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs? a.Liberally season foods. b.Initiate enteral feedings. c.Offer plenty of thin liquids. d.Encourage sweet foods.
b.Initiate enteral feedings.
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.A nasal cannula b.A ventilator c.A face mask d.A rigid shell
c.A face mask
A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to a.Wait 10 seconds before administering the second spray. b.Clean the medication container once each day. c.Blow the nose before applying medication into the nares. d.Tilt the head back when activating the spray of the medication.
c.Blow the nose before applying medication into the nares.
The nurse is caring for a client who just returned from an open lung biopsy and has a prescription for morphine by client controlled analgesia (PCA). Which of these actions to detect early opioid induced respiratory depression does the nurse recommend? a.Continuous pulse oximetry b.Serial arterial blood gas measurements c.Continuous capnography d.Apnea monitoring
c.Continuous capnography
The nurse is caring for a client with facial trauma who has recently developed restlessness. Which of these is the nurse's first priority? a.Assess for bleeding on the drip moustache dressing. b.Provide ventilation with a manual resuscitation bag. c.Perform the abdominal thrust maneuver. d.Apply oxygen.
d.Apply oxygen.
A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks? a.Administering nasal lavage b.Preparing the patient for a septoplasty c.Applying steroidal nasal spray d.Applying nasal packing
d.Applying nasal packing
The nurse assesses that the flap created after laryngectomy in the immediate post-operative period appears dusky in color. What is the nurse's first action? a.Apply moist heat over the flap site. b.Massage the flap site vigorously. c.Place a tight dressing over the flap. d.Assess flow to the area using a Doppler device.
d.Assess flow to the area using a Doppler device.
A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which preoperative intervention can be accomplished by an LPN/LVN working on the unit? a.Administering preoperative antibiotics and anxiolytics b.Assessing the client's nutritional status and need for nutrition supplements c.Having the client sign the operative consent form d.Teaching the client about the need for tracheal suctioning after surgery
a.Administering preoperative antibiotics and anxiolytics
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. a.Age b.Alcohol c.Region of country lived in d.Tobacco e.Industrial pollutants
a.Age b.Alcohol d.Tobacco e.Industrial pollutants
The community health nurse is providing education about risk factors for head and neck cancer? Which of these risks will be included in the teaching session? a.Alcohol and smokeless tobacco use b.Chronic laryngitis and voice abuse c.Marijuana use and exposure to industrial chemicals d.Poor oral hygiene and smoking cigarettes
a.Alcohol and smokeless tobacco use
A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first? a.Ask the client whether the mask fits tightly over the mouth and nose. b.Discuss the use of autotitrating positive airway pressure (APAP). c.Plan to teach the client about treatment with modafinil (Provigil). d.Suggest that a nasal mask be used instead of a full facemask.
a.Ask the client whether the mask fits tightly over the mouth and nose.
The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely? a.Asthma b.Acute respiratory obstruction c.Adult respiratory distress syndrome d.Pneumothorax
a.Asthma
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately? a.Bleeding b.Throat pain c.Difficulty talking d.Difficulty swallowing
a.Bleeding
The charge nurse in the emergency department (ED) is making assignments for the team including a new RN who has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse? a.Client on warfarin (Coumadin) with epistaxis with brisk bleeding b.Client with facial burns caused by a mattress fire while sleeping c.Client with possible facial fractures after a motor vehicle collision d.Client with suspected bilateral vocal cord paralysis and stridor
a.Client on warfarin (Coumadin) with epistaxis with brisk bleeding
The home health nurse is assigned to visit these clients when a change in agency staffing requires that one of the clients be rescheduled for a visit on the following day. Which client will be best to reschedule? a.Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% b.Client with history of a cough, weight loss, and night sweats who has just had a positive Man c.Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment d.Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea
a.Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93%
The emergency nurse is preparing to care for a client sustaining facial and neck injuries in a motor vehicle crash. Which of these is the priority at this time? a.Ensure a tracheostomy tray is at the bedside b.Place pressure on areas of hemorrhage c.Assess the mastoid area for battle sign d.Administer isotonic fluid replacement
a.Ensure a tracheostomy tray is at the bedside
A client with asthma reports shortness of breath. Which of these findings does the nurse anticipate when assessing this client's chest? a.Expiratory wheezing not cleared by coughing b.Bronchial breath sounds over the trachea c.Crackles throughout the lung fields d.Bronchovesicular breath sounds in the lung bases
a.Expiratory wheezing not cleared by coughing
The nurse in the medical clinic is performing an assessment on an older adult client. Which finding requires further assessment by the nurse? a.Inability to state name and date of birth b.Slight kyphoscoliosis c.Soft speaking voice d.Need to rest after activity
a.Inability to state name and date of birth
Which clinical manifestation of hemorrhage is related to carotid artery rupture? a.Increased pulse rate b.Increased blood pressure c.Dry skin d.Shallow respirations
a.Increased pulse rate
The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for? a.Iodine allergy b.Bleeding c.Dysrhythmias d.Inflammation
a.Iodine allergy
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. a.Lung sounds of wheezing b.Nasal flaring with abdominal retractions c.Administration of a corticosteroid inhaler for quick relief d.Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 e.Increased respiratory effort f.A decreased respiratory rate
a.Lung sounds of wheezing b.Nasal flaring with abdominal retractions d.Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 e.Increased respiratory effort
A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. What is the reason the client with suspected lung cancer would undergo magnetic resonance imaging (MRI)? a.MRI can view soft tissues and can help stage cancers. b.Lung blood flow can be viewed after a radiopaque agent is injected. c.Tumor densities can be seen with radiolucent images. d.Narrow-beam x-ray can scan successive lung layers.
a.MRI can view soft tissues and can help stage cancers.
A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis. a.On the cheeks below the eyes b.Behind the ethmoid sinuses c.Between the eyes and behind the nose d.Above the eyebrows
a.On the cheeks below the eyes
A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse? a.Pleurisy b.Bacterial pneumonia c.Lung infarction d.Bronchogenic carcinoma
a.Pleurisy
The nurse is assessing a client for obstructive sleep apnea (OSA). Which are signs and symptoms of OSA? Select all that apply. a.Polycythemia b.Pulmonary hypotension c.Insomnia d.Evening headaches e.Loud snoring
a.Polycythemia c.Insomnia e.Loud snoring
What is the primary function of the larynx? a.Producing sound b.Protecting the lower airway from foreign objects c.Preventing infection d.Facilitating coughing
a.Producing sound
The nurse is supervising a client during mealtime who has had a recent laryngectomy. Which of these is essential to include in the plan of care? a.Swallow twice to clear the airway b.Thicken all foods to a honey consistency c.Elevate the head of the bed to 45 degrees d.Review the results of the radiographic swallowing study
a.Swallow twice to clear the airway
A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub? a.No fluid is normally present b.20 mL or less c.20-40 mL d.More than 40 mL
b.20 mL or less
The nurse is assessing a patient who smokes 2 packs of cigarettes per day and has a strong family history of cancer. What early sign of cancer of the larynx does the nurse look for in this patient? a.Burning of the throat when hot liquids are ingested b.Affected voice sounds c.Enlarged cervical nodes d.Dysphagia
b.Affected voice sounds
A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to a.Apply an ice pack to the nose. b.Check the clear fluid for glucose. c.Reassure the client that the nose is not fractured. d.Administer prescribed oral ibuprofen (Motrin).
b.Check the clear fluid for glucose.
The nurse is assessing a client with chronic bronchitis who smoked 3 packs of cigarettes daily for 32 years. How does the nurse document pack-year history of smoking in the medical record? a.Client has a 32 pack-year history b.Client has a 96 pack-year history c.Client smoked 3 packs for years d.Client was a passive smoker for 32 years
b.Client has a 96 pack-year history
The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect? a.Infection b.Edema of the upper airway c.Postoperative bleeding d.Plugged tracheostomy tube
b.Edema of the upper airway
The nurse is preparing the client for a diagnostic bronchoscopy. Which nursing intervention is essential for the nurse to perform prior to the procedure? a.Obtain informed consent. b.Ensure the client has had nothing by mouth. c.Review dietary and medication allergies. d.Perform aggressive chest physiotherapy.
b.Ensure the client has had nothing by mouth.
The standard perioperative laryngectomy plan of care includes these interventions. Which intervention will be most important for the nurse to accomplish preoperatively? a.Educate the client about ways to avoid aspiration when swallowing after the surgery. b.Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. c.Discuss appropriate clothing to wear that will help cover the laryngectomy stoma and decrease social isolation after surgery. d.Teach the client and significant others about how to suction and perform wound care of the stoma.
b.Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board.
A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by: a.Inspecting the posterior region of the epiglottis. b.Inspecting the roof of the nasopharynx. c.Examining the base of the oropharynx. d.Palpating the throat above the cricoid cartilage.
b.Inspecting the roof of the nasopharynx.
The nurse is caring for the client who has had an open reduction and internal fixation (ORIF) with titanium plates to repair a LeFort III fracture. Which of these activities will the nurse include in the teaching plan? a.Individuals with a titanium plate should not have an MRI and should carry a wallet card stating this. b.It is important to have good oral hygiene using an irrigating device such as Waterpik. c.Let the health care team know if you are experiencing any pain. d.We will be checking behind your ear for any bruising to assess for additional trauma.
b.It is important to have good oral hygiene using an irrigating device such as Waterpik.
A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following? a.Client reports no chest pain. b.Lungs are clear on auscultation. c.Client can perform incentive spirometry. d.Respiratory rate is 12 to 18 breaths per minute.
b.Lungs are clear on auscultation.
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? a.Incrusted mucous membranes b.Noisy breathing c.Erosion of the trachea d.Hardened secretions
b.Noisy breathing
A patient is diagnosed as being in the early stage of laryngeal cancer of the glottis with only 1 vocal cord involved. For what type of surgical intervention will the nurse plan to provide education? a.Total laryngectomy b.Partial laryngectomy c.Vocal cord stripping d.Cordectomy
b.Partial laryngectomy
A client has a nursing diagnosis of acute pain related to upper airway irritation. The best short-term goal for this client is for the client to a.Gargle with a warm saline solution frequently. b.Report relief of pain to level 3 using a pain intensity scale of 0 to 10. c.Take acetaminophen with codeine when pain is 5 or above. d.Use a pain intensity rating scale of 1 to 10.
b.Report relief of pain to level 3 using a pain intensity scale of 0 to 10.
When caring for a client who has just undergone thoracentesis, which of these interventions does the nurse perform first? a.Encourage coughing and deep breathing. b.Schedule an immediate chest x-ray. c.Document the volume of removed fluid in the medical record. d.Set up a water seal drainage unit.
b.Schedule an immediate chest x-ray.
The emergency department nurse is assessing a client who believes he has sustained a pneumothorax after an outpatient thoracentesis earlier today. For which of these symptoms will the nurse assess? Select all that apply. a.Slowing heart rate b.Sensation of air hunger c.Tracheal deviation d.Pain on the unaffected side e.Blue discoloration of the lips
b.Sensation of air hunger c.Tracheal deviation e.Blue discoloration of the lips
The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes? a.They are heard in clients with decreased secretions. b.They can be heard during inspiration and expiration. c.They result from air passing through widened air passages. d.They occur when the pleural surfaces are inflamed.
b.They can be heard during inspiration and expiration.
The nurse in a life care community for geriatric clients is providing education to a group of residents on expected changes during aging. Which of these activities does the nurse encourage the older adult to perform to maintain respiratory function? a.Stay in bed to prevent fatigue. b.Walk as tolerated each day. c.Consume adequate calcium. d.Perform oral hygiene twice daily.
b.Walk as tolerated each day.
A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer? a.weight loss b.a feeling of swelling at the back of the throat c.discomfort when drinking cold liquids d.headaches in the morning
b.a feeling of swelling at the back of the throat
The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care? a.Encourage oral nutrition on the second postoperative day. b.Maintain the client in a low-Fowler's position. c.Develop an alternate method of communication. d.Assess the tracheostomy cuff for leaks.
c.Develop an alternate method of communication.
Which client does the charge nurse on the medical-surgical unit assign to an RN who has floated from the postanesthesia care unit (PACU)? a.Client with possible ulcer who just returned from an endoscopy b.Client with emphysema who needs teaching about pulmonary function testing c.Client with pancreatitis who needs a preoperative chest x-ray d.Client who had 1200 mL of pleural fluid removed by thoracentesis
d.Client who had 1200 mL of pleural fluid removed by thoracentesis
What client would be most in need of an endotracheal tube? a.Older adult clients b.A client status post tonsillectomy c.Ambulatory clients d.Comatose clients
d.Comatose clients
A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type? a.Rhonchi b.Pleural rub c.Wheezes d.Crackles
d.Crackles
You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis? a.Monitor for signs of dysphagia. b.Caution against frequent coughing. c.Provide meticulous mouth care every 4 hours. d.Encourage deep breathing every 2 hours.
d.Encourage deep breathing every 2 hours.
A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes a.Chronic obstructive pulmonary disease (COPD) b.Congestive heart failure (CHF) c.Respiratory failure (RF) d.Gastroesophageal reflux disease (GERD)
d.Gastroesophageal reflux disease (GERD)
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention? a.Aphonia following a football game b.Laryngitis following a cold c.Epistaxis, twice last week d.Hoarseness for 2 weeks
d.Hoarseness for 2 weeks
The nurse enters the room while the client is eating breakfast and recognizes that the client has an upper airway obstruction with signs of hypoxemia. What is the nurse's first action? a.Attempt to remove the obstruction. b.Call the Rapid Response Team (RRT). c.Apply oxygen by non-rebreathing mask. d.Perform the abdominal thrust maneuver.
d.Perform the abdominal thrust maneuver.
The RN and the LPN/LVN are working together to provide care for a group of clients on a medical surgical unit. Which of these actions is most appropriate for the RN to perform? a.Administer purified protein derivative (PPD) for tuberculosis testing. b.Assess vital signs and the puncture site one day post thoracentesis. c.Monitor oxygen saturation using pulse oximetry every 4 hours. d.Plan client and family teaching regarding upcoming pulmonary function testing.
d.Plan client and family teaching regarding upcoming pulmonary function testing.
The nurse is caring for a client with laryngeal trauma. Which sign/symptom does the nurse determine is most critical to report to the provider? a.Aphonia b.Hoarseness c.Loud snoring d.Stridor
d.Stridor
The nurse manager at a long-term-care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks is appropriate to delegate to a nursing assistant? a.Administering throat-numbing lozenges b.Assessing the mouth for inflammation and infection c.Teaching about skin care while receiving radiation d.Washing the skin with plain soap and water
d.Washing the skin with plain soap and water
The RN has received report about four clients. Which client needs the most immediate assessment? a.Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry b.Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes c.Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago d.Client with pleural effusion who has decreased breath sounds at the right base
a.Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation? a.Sudden restlessness b.Copious mucous secretions c.Rhonchi in lung fields d.Harsh cough
a.Sudden restlessness
A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation: a.is breathing air in and out of the lungs. b.helps people who cannot breathe on their own. c.provides a blood supply to the lungs. d.is when the body changes oxygen into CO2.
a.is breathing air in and out of the lungs.
The nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results? a.Reduced lighting in the room b.Increased temperature of the room c.Diagnosis of peripheral vascular disease d.Placement of the probe on an earlobe
c.Diagnosis of peripheral vascular disease
Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium? a.Hematoma b.Urge to cough c.Difficulty in breathing d.Absent distal pulses
c.Difficulty in breathing
The nurse in the outpatient clinic is scheduling a client for pulmonary function tests. When teaching the client about pulmonary function testing (PFT), which point is essential for the nurse to emphasize? a.Administer bronchodilator medication on call. b.Encourage clear fluid intake 12 hours before the procedure. c.Ensure the client does not smoke for 6 hours before the test. d.Provide supplemental oxygen.
c.Ensure the client does not smoke for 6 hours before the test.
The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse? a.Ecchymosis b.Edema c.Excessive swallowing d.Sore throat
c.Excessive swallowing
Which is the priority nursing diagnosis for a client undergoing a laryngectomy? a.Imbalanced nutrition: Less than body requirements b.Impaired verbal communication c.Ineffective airway clearance d.Anxiety and depression
c.Ineffective airway clearance
Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has? a.Cancer of the tonsils b.Cancer of the pharynx c.Laryngeal cancer d.Laryngeal polyps
c.Laryngeal cancer
When assessing a client, which adaptation indicates the presence of respiratory distress? a.Productive cough b.Sore throat c.Orthopnea d.Respiratory rate of 14 breaths per minute
c.Orthopnea
A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to a.Stay in bed when experiencing a fever b.Properly dispose of used tissues c.Seek medical help if he experiences inability to swallow d.Place an ice collar on the throat to relieve soreness
c.Seek medical help if he experiences inability to swallow
A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first a.Places both arms around the worker's waist b.Makes a fist with one hand with the thumb outside the fist c.Stands behind the worker, who has hands across the neck d.Exerts pressure against the worker's abdomen
c.Stands behind the worker, who has hands across the neck
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? a.Presence of carotid pulse b.Medication allergies c.Swallow reflex d.Ability to deep breathe
c.Swallow reflex
When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided? a.Wearing a scarf over the stoma b.Hand-held showers c.Swimming d.Coughing
c.Swimming
When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first? a.Contact the physician. b.Have the client blow his nose. c.Test the nasal drainage for glucose. d.Look for a halo sign after the drainage dries.
c.Test the nasal drainage for glucose.
The nurse is caring for four clients who came to the emergency department with a productive cough. Which of these clients requires immediate intervention by the nurse? a.The client with blood in the sputum b.The client with mucoid sputum c.The client with pink, frothy sputum d.The client with yellow sputum
c.The client with pink, frothy sputum
The nurse in the radiation therapy department is teaching the client about use of fluoride gel trays during radiation treatments. How will the nurse explain the purpose of wearing fluoride gel trays during radiation therapy of the mouth? a.They will keep the mouth moist during treatments. b.They prevent yellow teeth after treatment. c.They prevent radiation scatter from metal in the mouth. d.They will protect the taste buds on the tongue.
c.They prevent radiation scatter from metal in the mouth.
Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? a.Maximal voluntary ventilation b.Functional residual capacity c.Tidal volume d.Vital capacity
c.Tidal volume
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice? a.Partial laryngectomy b.Radiation therapy c.Total laryngectomy d.Laser surgery
c.Total laryngectomy
The nurse is planning care for the non-English-speaking client who is on complete voice rest after head and neck surgery. The nurse must verify the client's allergies prior to medication administration. What alternative method of communication is best for the nurse to use? a.Alphabet board b.Picture board c.Translation phone service d.Word board
c.Translation phone service
Which statement by a client with a laryngectomy indicates a need for further discharge teaching? a."I must avoid swimming." b."I can clean the stoma with soap and water." c."I can project mucus when I laugh or cough." d."I can't put anything over my stoma to cover it."
d."I can't put anything over my stoma to cover it."
A client's mother asks what is the most important thing she will need to know to care for her son, who is having an inner maxillary fixation for a mandibular fracture. Which of these does the nurse communicate as the priority? a."Make sure he gets enough calories each day." b."He can only consume milk and ice cream until the wires come off." c."He must brush his teeth every 2 hours." d."Make sure he always carries the wire cutters with him."
d."Make sure he always carries the wire cutters with him."
A client has returned to the medical surgical unit after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP)? a.Assess breath sounds. b.Offer clear liquids when gag reflex returns. c.Determine level of consciousness. d.Monitor blood pressure and pulse.
d.Monitor blood pressure and pulse.
