Chapter 9: PrepU - Nursing Management: Patients With Upper Respiratory Tract Disorders
A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis? 1- Group A, beta-hemolytic streptococci 2- Gram-negative Klebsiella 3- Pseudomonas aeruginosa 4- Staphylococcus aureus
1
Wound drains, inserted during the laryngectomy, stay in place until what criteria are met? 1- The stoma is healed, about 6 weeks after surgery. 2- The surgical site is dry with encrustations. 3- Drainage is <30 mL/day for 2 consecutive days. 4- The patient is able to assist with his own suctioning.
3
The nurse is providing care for a number of patients who are receiving treatment for health problems that have a respiratory etiology. Which of the following patients is most likely to benefit from the administration of a PO or IV diuretic? 1- A patient who presents with a barrel chest 2- A patient who has crackles on auscultation 3- A patient who has a sibilant wheeze 4- A patient who has recently complained of chest pain
2
A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated? 1- Tympanic 2- Resonant 3- Hyperresonant 4- Dull
4
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 1- Gastroesophageal reflux disease (GERD) 2- Chronic obstructive pulmonary disease (COPD) 3- Congestive heart failure (CHF) 4- Respiratory failure (RF)
1
What is the most commonly prescribed treatment for the common cold? 1- Antihistamines 2- Decongestants 3- Antitussives 5- Expectorants
1
Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction? 1- Apply a warm pack postoperatively 2- Ensure mouth breathing 3- Apply pressure to the convex portion of the nose 4- Provide a splint postoperatively
2
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? 1- The client will have decreased pain. 2- The client will remain alert and oriented. 3- The client will have decreased edema. 4- The client will have increased tissue perfusion.
3
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: 1- One vocal cord was removed along with a portion of the larynx. 2- The voice was spared and a tracheostomy would be in place until the airway was established. 3- A permanent tracheal stoma would be necessary. 4- A portion of the vocal cord was removed.
3
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: 1- lie supine with his neck extended. 2- sit upright, leaning slightly forward. 3- blow his nose and then put lateral pressure on his nose. 4- hold his nose while bending forward at the waist.
2
A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority? 1- Administer one intramuscular injection of penicillin. 2- Provide the client with oral penicillin that will last for 5 days. 3- Provide emphatic oral instructions for the client. 4- Ask an accompanying homeless friend to monitor the client's follow-up.
1
A patient diagnosed 2 weeks ago with acute pharyngitis comes to the clinic stating that the sore throat got better for a couple of days and is now back along with an earache. What complications should the nurse be aware of related to acute pharyngitis? (Select all that apply.) 1- Mastoiditis 2- Otitis media 3- Peritonsillar abscess 4- Pericarditis 5- Encephalitis
1,2,3
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? 1- Preparing the patient for a septoplasty 2- Applying nasal packing 3- Administering nasal lavage 4- Applying steroidal nasal spray
2
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? 1- A ventilator 2- A face mask 3- A rigid shell 4- A nasal cannula
2
A 23-year-old man has missed numerous work days over the past 2 years as a result of chronic viral pharyngitis. The nurse who is providing care for this patient should recognize that this patient may benefit from: 1- Intravenous antibiotics 2- Nebulized bronchodilators 3- Tonsillectomy 4- CPAP
3
A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for 1- Hypertension 2- Mild headache 3- Nuchal rigidity 4- Nausea
3
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? 1- "I have environmental allergies." 2- "I smoke a pack of cigarettes a day." 3- "I used my voice in excess over the weekend." 4- "I was chewing ice chips all day long."
4
The nurse is instructing a client who is scheduled for a laryngectomy about methods of laryngeal speech. Which best describes tracheoesophageal puncture (TEP)? 1- It requires the insertion of a prosthesis into the trachea. 2- It requires the client to hold a throat vibrator against the neck. 3- It enables the client to form words with the lips. 4- It will result in a low, gruff-sounding voice.
1
The health care provider has ordered continuous positive airway pressure (CPAP) with the delivery of oxygenation. The patient asks the nurse what the benefit of CPAP is. What would be the nurse's best response? 1- CPAP allows a higher percentage of oxygen to be used 2- CPAP prevents the collapse of the patient's airway 3- CPAP eliminates the need for oxygen supplementation during the day 4- CPAP alters alveolar perfusion
2
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 1- Wait 10 seconds before administering the second spray. 2- Tilt the head back when activating the spray of the medication. 3- Clean the medication container once each day. 4- Blow the nose before applying medication into the nares.
4
A nurse is aware that crackles, non-contiguous breath sounds, are assessed for a patient with: 1- Asthma 2- Chronic bronchitis 3- A collapsed alveoli 4- Pulmonary fibrosis
4
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 1- Apply an ice pack to the nose. 2- Reassure the client that the nose is not fractured. 3- Administer prescribed oral ibuprofen (Motrin). 4- Check the clear fluid for glucose.
1
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 1- Stands behind the worker, who has hands across the neck 2- Places both arms around the worker's waist 3- Makes a fist with one hand with the thumb outside the fist 4- Exerts pressure against the worker's abdomen
1
A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client: 1- Sleep with the head of bed elevated. 2- Caffeinated beverages are allowed. 3- You may drink 1 glass of alcohol daily. 4- Do not perform saline irrigations to the nares.
1
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following? 1- Partial laryngectomy 2- Supraglottic laryngectomy 3- Hemilaryngectomy 4- Total laryngectomy
1
A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection? 1- An antiviral agent such as acyclovir 2- An antibiotic such as amoxicillin 3- An antihistamine such as Benadryl 4- An ointment such as bacitracin
1
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately? 1- Bleeding 2- Difficulty swallowing 3- Throat pain 4- Difficulty talking
1
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of 1- 2 to 12 days. 2- 20 to 30 days. 3- 1 to 3 months. 4- 3 to 6 months.
1
The nurse in the ICU is caring for a client with a nasotracheal tube. Because of the tube placement, the nurse understands that the client is at risk for developing 1- sinus infection. 2- severe epistaxis. 3- subperiosteal abscess. 4- orbital cellulitis.
1
The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care? 1- Develop an alternate method of communication. 2- Encourage oral nutrition on the second postoperative day. 3- Maintain the client in a low-Fowler's position. 4- Assess the tracheostomy cuff for leaks.
1
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? 1- Initiate enteral feedings. 2- Offer plenty of thin liquids. 3- Encourage sweet foods. 4- Liberally season foods.
1
The nurse is caring for a client with allergic rhinitis. The c;ient asks the nurse about measures to help decrease allergic symptoms. Which is the best response by the nurse? 1- "You should try to reduce exposure to irritants and allergens." 2- "Be sure to receive your influenza vaccination each year." 3- "You need to see your ear, nose, and throat specialist monthly." 4- "Take over-the-counter nasal decongestants when you experience symptoms."
1
The nurse is caring for a patient in the outpatient clinic with suspicion of cancer due to recent weight loss for unidentifiable reasons. The patient has a 25-year history of smoking. The nurse performs an assessment and asks the patient about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer? 1- Hoarseness 2- Dyspnea 3- Dysphagia 4- Alopecia
1
The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed? 1- When the patient has less than 30 mL for 2 consecutive days 2- When the patient states that there is discomfort and requests removal 3- When the drainage tube comes out 4- In 1 week when the patient no longer has serous drainage
1
You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? 1- Airway patency 2- Level of consciousness 3- Psychologic status 4- Pain level
1
You are assessing the respiratory system of a client just admitted to your unit. What do you know to assess in addition to the physical and functional issues related to breathing? 1- How these issues affect the client's quality of life 2- How these issues affect the relationships in the client's life 3- How these issues affect the client's effort to breathe 4- How these issues affect the client's ability to function
1
The nurse is educating the patient diagnosed with acute pharyngitis on methods to alleviate discomfort. What interventions should the nurse include in the information? (Select all that apply.) 1- Apply an ice collar. 2- Stay on bed rest during the febrile stage of the illness. 3- Gargle with an alcohol-based mouthwash. 4- Try a liquid or soft diet during the acute stage of the disease. 5- Drink warm or hot liquids during the acute stage of the disease.
1,2,4
A patient with a diagnosis of acute rhinosinusitis has approached the nurse and asked for advice about "rinsing out my sinuses with saltwater," a treatment that was suggested by a friend. The nurse's response should be premised on which of the following statements? 1- Saline rinses have the potential to damage the mucosa of the sinuses. 2- Nasal saline lavage can help to improve the patency of the sinuses. 3- Nasal saline lavage can result in rebound congestion. 4- Rinsing with saline has been shown to be ineffective in clearing the sinuses of mucus.
2
During a period of significant workplace stress, a patient has been experiencing the recurrence of viral rhinitis for the past several weeks and claims that he has been unable to fully recover from this cold. The nurse should recognize that this patient is at risk of developing: 1- Epistaxis 2- Rhinosinusitis 3- Epiglottitis 4- Allergic rhinitis
2
During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events? 1- Pulmonary hypotension 2- Hypercapnia 3- Systemic hypotension 4- Increased smooth muscle contractility
2
The health care provider diagnosed a patient with subacute rhinosinusitis. The nurse knows that the inflammatory process had existed for: 1- 2 weeks. 2- 6 weeks. 3- 4 months. 4- 5 months.
2
The nurse is caring for a client diagnosed with rhinosinusitis. The physician has ordered the client to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the client that a common side effect of this medication is 1- Headache 2- Epistaxis 3- Arthralgia 4- Watery eyes
2
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? 1- Rhonchi in the bronchial region 2- Audible stridor without using a stethoscope 3- Crackles in the bases of the lungs 4- Diminished breath sounds throughout
2
The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose? 1- CBC with differential 2- Transillumination of the sinus 3- Nasal culture 4- Magnetic resonance imaging (MRI)
2
The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include? 1- "After surgery you will have a sore throat, but you will be able to speak." 2- "You can use writing or a communication board to communicate." 3- "After surgery you will have to use an electric larynx to communicate." 4- "A speech therapist will evaluate you and recommend a system of communication after surgery."
2
A 13-year-old soccer player presents to the emergency room with a fractured nose. The patient's mother is given which of the following post-discharge instructions? Select all that apply. 1- Apply ice or cold compresses for 20 minutes every hour for the first 24 hours. 2- Check for any unusual changes in breathing during the first 48 hours. 3- Observe for any clear drainage from either nostril. 4- Keep the nasal packing in place for 72 hours to help reshape the form of the nose. 5- Elevate the head of the bed for sleeping during the first week. 6- Restrict from sports activities for 6 weeks.
2, 3, 5, 6
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? 1- Client can perform incentive spirometry. 2- Lungs are clear on auscultation. 3- Respiratory rate is 12 to 18 breaths per minute. 4- Client reports no chest pain.
2- Lungs are clear on auscultation.
A client is experiencing acute viral rhinosinusitis. The nurse is providing instructions about self-care activities and includes information about 1- Cold compresses to the sinus cavities 2- Use of a dehumidifier 3- Saline lavages to the nares 4- Administration of oral antibiotics
3
A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to 1- Stay in bed when experiencing a fever 2- Properly dispose of used tissues 3- Seek medical help if he experiences inability to swallow 4- Place an ice collar on the throat to relieve soreness
3
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? 1- Infection 2- Postoperative bleeding 3- Edema of the upper airway 4- Plugged tracheostomy tube
3
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? 1- Obtain vital signs. 2- Monitor heart rhythm. 3- Auscultate lung sounds. 4- Assess capillary refill.
3
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? 1- Epistaxis, twice last week 2- Aphonia following a football game 3- Hoarseness for 2 weeks 4- Laryngitis following a cold
3
The nurse is preparing to perform tracheal suction for a patient who has had a tracheostomy for several months following a traumatic brain injury. After securing the end of the suction tubing to the suction device, the nurse should turn on suction source at a pressure that should not exceed: 1- 100 mm Hg 2- 125 mm Hg 3- 150 mm Hg 4- 175 mm Hg
3
The nurse is preparing to suction a patient with an endotracheal tube. What would be the nurse's first step in the suctioning process? 1- Explain the procedure to the patient before beginning and offer reassurance during suctioning. 2- Turn on suction source at or below 120 mm Hg. 3- Assess the patient's lung sounds and SaO2 via pulse oximeter. 4- Perform hand hygiene, then put on nonsterile gloves, goggles, gown, and mask.
3
Which is the priority nursing diagnosis for a client undergoing a laryngectomy? 1- Imbalanced nutrition: Less than body requirements 2- Impaired verbal communication 3- Ineffective airway clearance 4- Anxiety and depression
3
A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is 1- Acute pain related to upper airway irritation 2- Deficient fluid volume related to increased fluid needs 3- Deficient knowledge related to prevention of upper respiratory infections 4- Ineffective airway clearance related to excess mucus production
4
A female patient with obstructive sleep apnea (OSA) has been recommended a continuous positive airway pressure (CPAP) machine for the treatment of her health problem. The nurse's priority for patient education should be: 1- The need to use inhaled corticosteroids and bronchodilators each night prior to applying CPAP 2- The importance of participating in daily physical exercise when using CPAP on a regular basis 3- The need to have continuous pulse oximetry in place while the CPAP machine is in use 4- The importance of complying with CPAP despite the inconvenience associated with its use
4
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? 1- Burning of the throat when hot liquids are ingested 2- Enlarged cervical nodes 3- Dysphagia 4- Affected voice sounds
4
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? 1- Cancer of the pharynx 2- Laryngeal cancer 3- Laryngeal polyps 4- Cancer of the tonsils
2
A client with acute viral rhinosinusitis is being seen in a clinic. The nurse is providing discharge instructions and includes the following information: 1- Avoid air travel. 2- Make sure to follow antibiotic therapy. 3- Severe pain when palpating the sinuses is normal. 4- Dehumidify the air in the home.
1
The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client? 1- Avoid sports activities for 6 weeks. 2- Decrease the amount of daily fluids. 3- Take aspirin for nasal discomfort. 4- Administer normal saline nasal drops as ordered.
1
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? 1- Test the nasal drainage for glucose. 2- Look for a halo sign after the drainage dries. 3- Have the client blow his nose. 4- Contact the physician.
1
Which clinical manifestation of hemorrhage is related to carotid artery rupture? 1- Increased pulse rate 2- Increased blood pressure 3- Shallow respirations 4- Dry skin
1
Which intervention regarding nutrition is implemented for clients who have undergone laryngectomy? 1- Use enteral feedings after the procedure 2- Offer plenty of thin liquids when intake resumes 3- Season food to suit an increased sense of taste and smell 4- Recommend the long-term use of zinc lozenges
1
An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by periods of breathing cessation for: 1- 4 seconds with 2 episodes/hour. 2- 6 seconds with 3 episodes/hour. 3- 8 seconds with 4 episodes/hour. 4- 10 seconds with 5 episodes/hour.
4
An emergency department (ED) nurse is assessing a 20-year-old gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from the nose. What should the ED nurse suspect? 1- Fracture of the cribriform plate 2- Potential loss of consciousness 3- Abrasion of the soft tissue 4- Fracture of the nasal septum
1
Bleeding from the drains at the surgical site or with tracheal suctioning may signal the occurrence of hemorrhage. Which of the following is a clinical manifestations associated with hemorrhage? 1- Rapid, deep respirations 2- Decreased pulse rate 3- Increased blood pressure 4- Warm, moist skin
1
Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require? 1- Emotional support 2- Referral for counseling 3- Family counseling 4- Referral for vocational training
1
Most cases of acute pharyngitis are caused by which of the following? 1- Viral infection 2- Bacterial infection 3- Fungal infection 4- Systemic infection
1
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: 1- lips. 2- mucous membranes. 3- nail beds. 4- earlobes.
2
A nurse is providing care to a client who is receiving mechanical ventilation via a cuffed endotracheal tube. When measuring cuff pressure, which reading would the nurse interpret as reducing the client's risk for injury? 1- 20cm H2O 2- 28cm H2O 3- 30cm H2O 4- 35cm H2O
1
Your client has had laryngeal surgery. What is as expected outcome in this client? 1- The client's suture line remains intact. 2- The client maintains an adequate caloric intake. 3- The client can swallow without difficulty. 4- The client's breathing patterns improve.
2
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? 1- Incrusted mucous membranes 2- Hardened secretions 3- Erosion of the trachea 4- Noisy breathing
4
A 13-year-old boy has been brought to the emergency department by his mother after he took a powerful blow to his nose during a volleyball game. Preliminary examination suggests a nasal fracture, which should prompt the nurse to: 1- Apply ice and tell the patient to keep his head elevated 2- Administer saline lavage and tell the patient not to swallow the solution 3- Apply warm compresses to the bridge of the patient's nose 4- Administer analgesia and a nebulized bronchodilator
1
A client exhibits a sudden and complete loss of voice and is coughing. The nurse states 1- "Do not smoke and avoid being around others who are smoking." 2- "It is fine to speak in a whisper. This does not strain your voice." 3- "Do not use a humidifier; it will make your problem worse." 4- "The 'tickle' in your throat will improve with cold liquids."
1
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? 1- a feeling of swelling at the back of the throat 2- weight loss 3- discomfort when drinking cold liquids 4- headaches in the morning
1
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 1- Report relief of pain to level 3 using a pain intensity scale of 1 to 10. 2- Take acetaminophen with codeine when pain is 5 or above. 3- Gargle with a warm saline solution frequently. 4- Use a pain intensity rating scale of 0 to 10.
1
A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever, and dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may predispose the client to sinusitis? 1- interference with sinus drainage 2- excessive protein intake 3- more than 8 hours of sleep per night 4- increased exposure to the health care environment
1
Select the nursing diagnosis that would warrant immediate health care provider notification. 1- Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation 2- Acute pain related to upper airway irritation secondary to an infection 3- Deficient fluid volume related to decreased fluid intake and increased fluid loss secondary to diaphoresis associated with a fever 4- Deficient knowledge regarding prevention of upper airway infections, treatment regimens, the surgical procedure, or postoperative care
1
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of 1- 2 to 12 days 2- 20 to 30 days 3- 1 to 3 months 4- 3 to 6 months
1
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? 1- "Clean the tracheostomy tube with alcohol and water." 2- "Family members should continue to talk to the client." 3- "Oral intake of fluids should be limited for 1 week only." 4- "Limit the amount of protein in the diet."
2
A college student has sought care at the campus medical clinical after a 5-day history of malaise that he believes is due to a bad cold. Which of the student's following statements should cause the nurse to suspect an alternative diagnosis? 1- "I never normally get headaches, but I've had a splitting headache for days." 2- "My eyes and ears are so itchy that it's driving me crazy." 3- "I've been burning up with a fever at night and then getting terrible chills too." 4- "My nose is raw because of my runny nose and sneezing."
3
