Chapter 29: Care of Patients with Noninfectious Upper Respiratory Problems Nursing School Test Banks

Chapter 29: Care of Patients with Noninfectious Upper Respiratory Problems
Ignatavicius: Medical-Surgical Nursing, 8th Edition

MULTIPLE CHOICE

1. A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?
a. Facial pain
b. Vital signs
c. Bone displacement
d. Airway patency
ANS: D
A patent airway is the priority. The nurse first should make sure that the airway is patent and then should determine whether the client is in pain and whether bone displacement or blood loss has occurred.

DIF: Applying/Application REF: 531
KEY: Trauma| medical emergencies
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

2. A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?
a. Collect the nasal drainage on a piece of filter paper.
b. Encourage the client to blow his or her nose.
c. Perform a test focused on a neurologic examination.
d. Palpate the nose, face, and neck.
ANS: A
The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the clients risk for infection.

DIF: Applying/Application REF: 532
KEY: Trauma| medical emergencies
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first?
a. Contact the provider for a prescription for sleep medication.
b. Tell the client not to drink beverages with caffeine before bed.
c. Educate the client to sleep upright in a reclining chair.
d. Ask the client if he or she has ever been evaluated for sleep apnea.
ANS: D
Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment.

DIF: Applying/Application REF: 535
KEY: Respiratory distress/failure
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration?
a. Tilt the head back as far as possible when swallowing.
b. Tuck the chin down when swallowing.
c. Breathe slowly and deeply while swallowing.
d. Keep the head very still and straight while swallowing.
ANS: B
The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration, but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration.

DIF: Applying/Application REF: 535
KEY: Aspiration precaution MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?
a. A 26-year-old woman who is 8 months pregnant
b. A 42-year-old man with gastroesophageal reflux disease
c. A 55-year-old woman who is 50 pounds overweight
d. A 73-year-old man with type 2 diabetes mellitus
ANS: C
The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.

DIF: Applying/Application REF: 535
KEY: Respiratory distress/failure
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance

6. After teaching a client who is prescribed voice rest therapy for vocal cord polyps, a nurse assesses the clients understanding. Which statement indicates the client needs further teaching?
a. I will stay away from smokers to minimize inhalation of secondhand smoke.
b. When I speak, I will whisper rather than use a normal tone of voice.
c. For the next several weeks, I will not lift more than 10 pounds.
d. I will drink at least three quarts of water each day to stay hydrated.
ANS: B
Treatment for vocal cord polyps includes no speaking, no lifting, and no smoking. The client has to be educated not to even whisper when resting the voice. It is also appropriate for the client to stay out of rooms where people are smoking, to stay hydrated, and to use stool softeners.

DIF: Applying/Application REF: 536
KEY: Cancer| patient education MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first?
a. Initiate Standard Precautions.
b. Apply direct pressure.
c. Sit the client upright.
d. Loosely pack the nares with gauze.
ANS: A
The nurse should implement Standard Precautions and don gloves prior to completing the other actions.

DIF: Applying/Application REF: 532 KEY: Trauma
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

8. A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first?
a. Ask the client to gargle with mouthwash containing lidocaine.
b. Administer prescribed intravenous pain medications.
c. Explain that soreness is normal and will improve in a couple days.
d. Assess the clients neck for redness and swelling.
ANS: A
Mouthwashes and throat sprays containing a local anesthetic agent such as lidocaine or diphenhydramine can provide relief from a sore throat after radiation therapy. Intravenous pain medications may be used if local anesthetics are unsuccessful. The nurse should explain to the client that this is normal and assess the clients neck, but these options do not decrease the clients discomfort.

DIF: Remembering/Knowledge REF: 539
KEY: Cancer| pain| medication
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

9. A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond?
a. I will consult the speech therapist to ensure you are swallowing properly.
b. This is normal after surgery. What types of food do you like to eat?
c. I will ask the dietitian to change the consistency of the food in your diet.
d. Replacement of protein, calories, and water is very important after surgery.
ANS: B
Many clients experience changes in taste after surgery. The nurse should identify foods that the client wants to eat to ensure the client maintains necessary nutrition. Although the nurse should collaborate with the speech therapist and dietitian to ensure appropriate replacement of protein, calories, and water, the other responses do not address the clients concerns.

DIF: Applying/Application REF: 533
KEY: Surgical care| nutrition
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

10. A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery?
a. Assess airway patency, breathing, and circulation.
b. Administer prescribed intravenous pain medication.
c. Assist the client to choose a communication method.
d. Ambulate the client in the hallway to assess gait.
ANS: C
The client will not be able to speak after surgery. The nurse should assist the client to choose a communication method that he or she would like to use after surgery. Assessing the clients airway and administering IV pain medication are done after the procedure. Although ambulation promotes health and decreases the complications of any surgery, this clients gait should not be impacted by a total laryngectomy and therefore is not a priority.

DIF: Applying/Application REF: 540 KEY: Surgical care
MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity

11. While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?
a. Contact the provider and prepare for intubation.
b. Administer prescribed albuterol nebulizer therapy.
c. Place the client in high-Fowlers position.
d. Ask the client to perform deep-breathing exercises.
ANS: A
Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and restlessness, should be immediately intubated to ensure airway patency. Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema. Although putting the client in high-Fowlers position and asking the client to perform breathing exercises may temporarily improve the clients comfort, these actions will not decrease the underlying problem or improve airway patency.

DIF: Applying/Application REF: 534 KEY: Trauma
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

12. A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, How will this medication help me? How should the nurse respond?
a. This medication will treat your sleep apnea.
b. This sedative will help you to sleep at night.
c. This medication will promote daytime wakefulness.
d. This analgesic will increase comfort while you sleep.
ANS: C
Modafinil is helpful for clients who have narcolepsy (uncontrollable daytime sleep) related to sleep apnea. This medication promotes daytime wakefulness.

DIF: Remembering/Knowledge REF: 535 KEY: Medication
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

13. A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first?
a. Assess the clients pain level.
b. Keep the clients head elevated.
c. Teach the client about the causes of nasal bleeding.
d. Make sure the string is taped to the clients cheek.
ANS: D
The string should be attached to the clients cheek to hold the packing in place. The nurse needs to make sure that this does not move because it can occlude the clients airway. The other options are good interventions, but ensuring that the airway is patent is the priority objective.

DIF: Applying/Application REF: 533 KEY: Surgical care
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

14. A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this clients teaching?
a. Add peppermint oil to the humidifier to relax the airway.
b. Make sure you clean the humidifier to prevent infection.
c. Keep the humidifier filled with water at all times.
d. Use the humidifier when you sleep, even during daytime naps.
ANS: B
Priority teaching related to the use of a room humidifier focuses on infection control. Clients should be taught to meticulously clean the humidifier to prevent the spread of mold or other sources of infection. Peppermint oil should not be added to a humidifier. The humidifier should be refilled with water as needed and should be used while awake and asleep.

DIF: Understanding/Comprehension REF: 544 KEY: Surgical care
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

MULTIPLE RESPONSE

1. A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.)
a. Observe for clear drainage.
b. Assess for signs of bleeding.
c. Watch the client for frequent swallowing.
d. Ask the client to open his or her mouth.
e. Administer a nasal steroid to decrease edema.
f. Change the nasal packing.
ANS: A, B, C, D
The nurse should observe for clear drainage because of the risk for cerebrospinal fluid leakage. The nurse should assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding. The nurse should also note whether the client is swallowing frequently because this could indicate postnasal bleeding. A nasal steroid would increase the risk for infection. It is too soon to change the packing, which should be changed by the surgeon the first time.

DIF: Applying/Application REF: 531 KEY: Surgical care
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.)
a. Diabetes mellitus
b. Hypertension
c. Leukemia
d. Cocaine use
e. Migraine
f. Elevated platelets
ANS: B, C, D
Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures. Diabetes, migraines, and elevated platelets and cholesterol levels do not cause epistaxis.

DIF: Understanding/Comprehension REF: 532
KEY: Respiratory distress/failure
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.)
a. Stridor
b. Nasal stuffiness
c. Edema of the cheek
d. Ecchymosis behind the ear
e. Eye pain
f. Swollen chin
ANS: A, D
Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis, or bruising, behind the ear is called battle sign and indicates basilar skull fracture.
Nasal stuffiness, edema of the cheek or chin, and eye pain do not interfere with respirations or neurologic function, and therefore are not priorities for immediate intervention.

DIF: Applying/Application REF: 534
KEY: Trauma| medical emergencies
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

4. A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.)
a. A 32-year-old who had a radical neck dissection 6 hours ago
b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago
c. A 55-year-old who needs discharge teaching after a laryngectomy
d. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer
e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement
ANS: B, E
The nurse can delegate stable clients to the LPN. The client who had a biopsy 2 days ago and the client who is awaiting gastric tube placement are stable. The client who is 6 hours post-surgery is not yet stable. The RN is the only one who can perform discharge and preoperative teaching; teaching cannot be delegated.

DIF: Applying/Application REF: 540
KEY: Interdisciplinary team| delegation MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

5. A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this clients teaching? (Select all that apply.)
a. You will need to cut the wires if you start vomiting.
b. Eat six soft or liquid meals each day while recovering.
c. Irrigate your mouth every 2 hours to prevent infection.
d. Sleep in a semi-Fowlers position after the surgery.
e. Gargle with mouthwash that contains Benadryl once a day.
ANS: A, B, C, D
The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. The client should also be taught to eat soft or liquid meals multiple times a day, irrigate the mouth with a Waterpik to prevent infection, and sleep in a semi-Fowlers position to assist in avoiding aspiration. Mouthwash with Benadryl is used for clients who have mouth pain after radiation treatment; it is not used to treat pain in a client with a mandibular fracture.

DIF: Applying/Application REF: 534
KEY: Surgical care| aspiration precautions
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.)
a. A 24-year-old with a traumatic brain injury
b. A 36-year-old who fractured his left femur
c. A 58-year-old at risk for aspiration following radiation therapy
d. A 66-year-old who is a quadriplegic and has a sacral ulcer
e. An 80-year-old who is aphasic after a cerebral vascular accident
ANS: A, C, D, E
Risk for asphyxiation related to inspissated oral and nasopharyngeal secretions is caused by poor oral hygiene. Clients at risk include those with altered mental status and level of consciousness (traumatic brain injury), dehydration, an inability to communicate (aphasic) and cough effectively (quadriplegic), and a risk of aspiration (aspiration precautions). The client with a fractured femur is at risk for a pulmonary embolism.

DIF: Applying/Application REF: 536
KEY: Medical emergencies
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

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