Chapter 27: Nursing Management: Upper Respiratory Problems Nursing School Test Banks

Chapter 27: Nursing Management: Upper Respiratory Problems

Test Bank

MULTIPLE CHOICE

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.

ANS: D

Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs, such as ibuprofen, increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not be taught to remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result, especially in the first few weeks after surgery.

DIF: Cognitive Level: Apply (application) REF: 498

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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.

ANS: D

The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Acute viral rhinitis (the common cold) can be prevented by washing hands.

DIF: Cognitive Level: Apply (application) REF: 500

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

3. 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.

ANS: C

The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.

DIF: Cognitive Level: Apply (application) REF: 502

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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.

ANS: C

This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.

DIF: Cognitive Level: Apply (application) REF: 510

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

5. 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.

ANS: C

Because the cuff is deflated when using a fenestrated tube, the patients risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patients airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patients vocal cords when using a fenestrated tube.

DIF: Cognitive Level: Apply (application) REF: 511

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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 removed.

ANS: A

Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patients airway is occluded. A health care providers order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings.

DIF: Cognitive Level: Apply (application) REF: 509

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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.

ANS: A

Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with nonalcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy.

DIF: Cognitive Level: Apply (application) REF: 515-516

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

8. 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?

ANS: A

Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patients symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patients symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever.

DIF: Cognitive Level: Apply (application) REF: 515

TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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 wont be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed.

c.

You wont 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.

ANS: D

Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.

DIF: Cognitive Level: Apply (application) REF: 516

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

10. 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.

ANS: C

Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.

DIF: Cognitive Level: Apply (application) REF: 518

TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

11. 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.

ANS: A

The stoma may be covered with clothing or a loose dressing, but this is not essential. An occlusive dressing will completely block the patients airway. The other patient comments are all accurate and indicate that the teaching has been effective.

DIF: Cognitive Level: Apply (application) REF: 517

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

12. 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 patients nose and cheeks.

ANS: A

The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area, but will not be sufficient to stop bleeding. Cauterization and nasal packing are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed.

DIF: Cognitive Level: Apply (application) REF: 499

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

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-Fowlers position.

ANS: D

The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowlers position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube.

DIF: Cognitive Level: Apply (application) REF: 516

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

14. 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 patients 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.

ANS: B

The first action should be to attempt to reinsert the tracheostomy tube to maintain the patients airway. Assessing the patients oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.

DIF: Cognitive Level: Apply (application) REF: 509

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

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

ANS: A

The patients clinical manifestation of a muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems.

DIF: Cognitive Level: Analyze (analysis) REF: 507

OBJ: Special Questions: Prioritization; Multiple Patients

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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

ANS: B

The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the-counter (OTC) pain relievers and increased fluid intake.

DIF: Cognitive Level: Apply (application) REF: 503

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

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 patients 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.

ANS: B

Suctioning of a stable patient can be delegated to LPNs/LVNs. Patient assessment and patient teaching should be done by the RN.

DIF: Cognitive Level: Apply (application) REF: 518

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

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 patients temperature is 100.1 F (37.8 C).

d.

The patient complains of level 8 (0 to 10 scale) pain.

ANS: A

Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the low O2 saturation.

DIF: Cognitive Level: Apply (application) REF: 499

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

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

ANS: A

Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate any complications.

DIF: Cognitive Level: Apply (application) REF: 498

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

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.

ANS: D

Because the highest priority action is to remove the foreign object from the nare, the nurses first action should be to assist the patient to remove the object. The other actions are also appropriate but should be done after attempting to clear the nose.

DIF: Cognitive Level: Apply (application) REF: 506

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

21. 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).

ANS: D

Oral or pharyngeal fungal infections are treated with nystatin solution. The goal of the swish and swallow technique is to expose all of the oral mucosa to the antifungal agent. Warm liquids may be soothing to a sore throat. The patient should be taught to use a cool mist humidifier. There is no need to assess for penicillin/cephalosporin allergies because Candida albicans infection is treated with antifungals.

DIF: Cognitive Level: Apply (application) REF: 506-507

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

22. 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).

ANS: B

The patients clinical manifestations are consistent with streptococcal pharyngitis and the nurse will anticipate the need for a rapid strep antigen test and/or cultures. Because patients with streptococcal pharyngitis usually do not have a cough, use of expectorants will not be anticipated. Rinsing the mouth out after inhaler use may prevent fungal oral infections, but the patients assessment data are not consistent with a fungal infection. NSAIDs are frequently prescribed for pain and fever relief with pharyngitis.

DIF: Cognitive Level: Apply (application) REF: 506

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. 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.

e.

You will be more comfortable if you keep your head in an upright position.

ANS: A, C, D, E

The steam and heat from a shower will help thin secretions and improve drainage. Decongestants can be used to relieve swelling. Patients can use either over-the-counter (OTC) sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.

DIF: Cognitive Level: Analyze (analysis) REF: 506

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

2. 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

ANS: A, B, D

Current guidelines suggest that healthy individuals between 6 months and age 49 receive intranasal immunization with live, attenuated influenza vaccine. Individuals who are pregnant, residents of nursing homes, or are immunocompromised or who have chronic medical conditions should receive inactivated vaccine by injection. The corticosteroid use by the 30-year-old increases the risk for infection.

DIF: Cognitive Level: Apply (application) REF: 504

OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning

MSC: NCLEX: Health Promotion and Maintenance

OTHER

1. 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.

ANS:

A, B, D, C

The patient should first be placed in a semi-Fowlers position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the wound drain should be drained because the 200 mL of drainage will decrease the amount of suction in the wound drain and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting.

DIF: Cognitive Level: Analyze (analysis) REF: 516

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

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