Chapter 30: Disorders of the Upper Respiratory Tract Nursing School Test Banks

Chapter 30: Disorders of the Upper Respiratory Tract
Linton: Introduction to Medical-Surgical Nursing, 6th Edition

MULTIPLE CHOICE

1. What portion of the internal nose traps particles and kills bacteria?
a. Turbinates
b. Mucous membrane
c. Vestibular formations
d. Cilia
ANS: B
The mucous membrane traps particles and bacteria that are inhaled; then an enzyme in the mucus destroys them. The cilia then sweep the particles into the throat to be swallowed.

DIF: Cognitive Level: Knowledge REF: p. 531 OBJ: 4
TOP: Anatomy and Physiology of the Nose
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. What is the function of the tonsils and adenoids in small children?
a. Help promote antibody formation
b. Assist in some digestive processes
c. Protect against bacterial infections of the throat
d. Support blood cell production
ANS: C
The tonsils and adenoids consist of lymphatic tissue that acts as a bacterial barrier for the respiratory and gastrointestinal tracts.

DIF: Cognitive Level: Knowledge REF: p. 532 OBJ: 4
TOP: Tonsils KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. A patient comes into the clinic complaining of a runny nose and facial pain. What should the nurses initial assessment include?
a. Assessment for nasal drainage and sinus tenderness
b. Transillumination and nasal speculum examination
c. Palpation of the frontal and maxillary sinuses and tonsillar inspection
d. Turbinate assessment and assessment for patency of the nares
ANS: A
The assessment of the characteristics of the nasal drainage and location of the facial pain would be the first evaluation for sinusitis.

DIF: Cognitive Level: Application REF: p. 533 OBJ: 2
TOP: Physical Examination of the Nose KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

4. A 68-year-old patient tells the nurse that her sense of smell is not as acute as before, her nose is drier, and she occasionally gets a nosebleed. What should the nurse suspect?
a. An infection
b. Normal age-related changes
c. A nasal defect
d. Allergies that are causing her symptoms
ANS: B
These options describe normal age-related changes. A suggestion that would make the patient more comfortable would be to use a humidifier to keep the mucous membranes moist.

DIF: Cognitive Level: Application REF: p. 533 OBJ: 2
TOP: Age-Related Changes in the Nose and Sinuses
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. What does age-related relaxation of the esophageal sphincter in a 70-year-old patient cause?
a. Excessive belching
b. Dumping syndrome
c. Tickling sensation, requiring frequent coughing
d. Burning in the throat when lying down
ANS: D
A common age-related change in the throat is a weakened esophageal sphincter. This allows gastric contents to flow back up into the throat and irritate the larynx. Elevating the head of the bed is a common treatment.

DIF: Cognitive Level: Comprehension REF: p. 533 OBJ: 4
TOP: Age-Related Changes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. When a patient with sleep apnea says, Im not wearing that silly mask. I look like something out of Star Wars, what should the nurse remind the patient about the function of the mask?
a. Increases oxygen intake
b. Stimulates regular respirations
c. Sounds an alarm when the oxygen concentration drops
d. Uses positive pressure to keep the airway open
ANS: D
The sleep apnea mask, through positive pressure, keeps the airway open during sleep.

DIF: Cognitive Level: Comprehension REF: p. 547 OBJ: 4
TOP: Sleep Apnea Mask KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

7. What should patient education for a patient being given nose drops for the first time include?
a. Asking the patient to sit down and tip her head to the side to allow for a better angle for the instillation of the drops
b. Holding the dropper against the side of the nose so that all the medication flows into the nares
c. Asking the patient to return any unused medication to the bottle
d. Tipping the head back and holding the dropper over the nostril and then telling the patient to keep her head back for a few minutes
ANS: D
Appropriate instillation of nose drops requires that the head be tipped back and the bottle not touch the nose.

DIF: Cognitive Level: Comprehension REF: p. 535 OBJ: 3
TOP: Nose Drops KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

8. A patient comes into the clinic complaining of waking up with a dry mouth and nose and asks if the dryness has caused the colds she has had in the past few months. What is the most appropriate suggestion for the nurse to suggest?
a. Use a humidifier at home.
b. Get a throat culture.
c. Get a nose culture.
d. Request an antibiotic.
ANS: A
A humidifier would be helpful in keeping the nasal mucous membranes moist, which can decrease nasal infections.

DIF: Cognitive Level: Analysis REF: p. 535 OBJ: 3
TOP: Humidification KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

9. Which assessment should indicate the necessity for a nurse to suction a patient with a tracheostomy?
a. Becomes restless and has increases in vital signs
b. Has decreased peak airway pressure
c. Shows diaphoresis
d. Is coughing frothy mucus
ANS: A
The patient signals the need for suctioning by increased restlessness and an increase in vital signs. Peak airway pressures increase when suctioning is necessary. Frothy mucus is an expectation.

DIF: Cognitive Level: Application REF: p. 535 OBJ: 3
TOP: Suctioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk

10. Which position is the most appropriate for a patient returning from surgery with a nasal pack and mustache dressing?
a. Side-lying position to prevent aspiration of drainage
b. Semi-Fowler position and apply a warm compress to reduce pain
c. High Fowler position and apply a cold dressing to reduce swelling
d. Sims position and apply a cold dressing to facilitate drainage and reduce swelling
ANS: C
Patients who have a nasal pack should be placed in semi- or high Fowler position with a cold dressing. The position and cold dressing will reduce swelling. Any side-lying position makes it more difficult for the patient to breathe with a nasal pack in place.

DIF: Cognitive Level: Application REF: p. 539 OBJ: 4
TOP: Nasal Pack KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

11. What intervention should a nurse implement when providing tracheostomy care?
a. Wash and rinse the inner cannula in tap water and then dry it.
b. Use a sterile solution of normal saline or other solution to wash the inner cannula and then rinse with sterile water.
c. Clean the area around the stoma with tap water and a gentle soap.
d. Remove the inner cannula, wash both hands with a bactericidal soap, and then don sterile gloves to clean the inner cannula.
ANS: B
The recommendation is to use a sterile technique for tracheotomy care.

DIF: Cognitive Level: Application REF: p. 538 OBJ: 5
TOP: Tracheostomy Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

12. What is the most appropriate nursing diagnosis for a patient who has had nose surgery?
a. Risk for imbalanced body temperature
b. Social isolation
c. Decreased cardiac output
d. Risk for activity intolerance
ANS: C
The nose has a large number of blood vessels, which cause a great deal of bleeding during surgery. Decreased cardiac output is the postoperative result.

DIF: Cognitive Level: Application REF: p. 539 OBJ: 5
TOP: Nasal Surgery KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk

13. A patient complains of morning headaches, a feeling of fullness in her head, and a pain similar to that of a toothache under her eye. What should the nurse recognize that these symptoms indicate?
a. Nasal polyps
b. Impacted wisdom teeth
c. Allergic rhinitis
d. Sinusitis
ANS: D
Sinusitis has the classic signs of headache, sense of fullness in the head, and a sensitive area over the sinuses.

DIF: Cognitive Level: Comprehension REF: p. 539-540 OBJ: 4
TOP: Sinusitis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

14. A patient complains that he wants an antibiotic medication for his cold. What is the best response by the nurse?
a. Antibiotics are not effective with viral infections.
b. You will get better faster without the antibiotics.
c. You might try echinacea or vitamin C.
d. A cold is not that serious. Try forcing fluids.
ANS: A
Antibiotics are not appropriate with colds because colds are caused by viruses. Overuse of antibiotics can promote resistant strains of bacteria to develop.

DIF: Cognitive Level: Comprehension REF: p. 541 OBJ: 4
TOP: Acute Viral Coryza KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

15. What should the initial action of a nurse be when providing first aid to a person with spontaneous epistaxis?
a. Apply direct pressure for 3 to 5 minutes.
b. Have the person sit down and lean forward.
c. Have the person lie down and apply an ice pack.
d. Have the person clear the nasal passages by blowing the nose.
ANS: B
The first action is to sit down and lean forward. Applying pressure just below the nose will also help.

DIF: Cognitive Level: Application REF: p. 542 OBJ: 4
TOP: Epistaxis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk

16. The patient has had anterior nasal packing placed for severe epistaxis. The nurse notes that he is swallowing frequently. What should a nurse suspect?
a. The patients throat is dry.
b. Posterior packing is uncomfortable.
c. The patient is bleeding.
d. The patients saliva production is excessive.
ANS: C
Frequent swallowing after nasal surgery is a sign of bleeding.

DIF: Cognitive Level: Analysis REF: p. 539 OBJ: 3
TOP: Epistaxis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

17. What is true regarding bacterial pharyngitis that is untrue for viral pharyngitis?
a. Has an abrupt onset
b. Presents a normal complete blood count (CBC)
c. Presents a negative culture
d. Has no serious complications
ANS: A
Bacterial pharyngitis has an abrupt onset, an elevated white count on the CBC, and a positive culture and can lead to glomerulonephritis, rheumatic fever, and mastoiditis.

DIF: Cognitive Level: Comprehension REF: p. 544 OBJ: 4
TOP: Bacterial Pharyngitis KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

18. Which is the best candidate for a tonsillectomy?
a. A 52-year-old patient with a hearing deficit related to otitis media from tonsillitis
b. A 23-year-old patient with a peritonsillar abscess
c. A 34-year-old patient with enlarged tonsils and adenoids
d. A 15-year-old patient with one bout of tonsillitis in the previous 12 months
ANS: B
The patient with the peritonsillar abscess is the most likely candidate. The hearing deficit in a middle-aged person would need more investigation before surgery. Enlarged tonsils and adenoids without a respiratory obstruction does not qualify as a need for surgery; only one episode of tonsillitis in a year does not qualify.

DIF: Cognitive Level: Analysis REF: p. 545 OBJ: 4
TOP: Tonsillitis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

19. What is best for a nurse to offer when encouraging a new patient after a tonsillectomy to increase fluids?
a. Chilled citrus juices
b. Tap water sipped through a straw
c. Flavored popsicles to suck
d. Ice cubes
ANS: C
Flavored popsicles provide fluid and cold applications to the surgical area. Citrus juices, the use of a straw, and ice cubes have the potential to injure the operative site.

DIF: Cognitive Level: Application REF: p. 547 OBJ: 5
TOP: Posttonsillectomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

20. What are the most common causes of laryngitis?
a. Smoking and highly seasoned foods
b. Alcohol and voice strain
c. Nasal congestion and frequent coughing
d. Respiratory infections and voice strain
ANS: D
Upper respiratory infections and voice strain are the most common causes of laryngitis.

DIF: Cognitive Level: Knowledge REF: p. 548 OBJ: 4
TOP: Disorders of the Larynx KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

21. What is the most significant topic for a nurse to include in a teaching plan for a patient with frequent episodes of laryngitis?
a. Observing voice rest
b. Reducing smoking
c. Eating warm foods
d. Maintaining a consistent environmental temperature
ANS: A
Patients with laryngitis are advised to rest their voices.

DIF: Cognitive Level: Comprehension REF: p. 549 OBJ: 5
TOP: Implementations for Laryngitis KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

22. A patient who has cancer of the larynx has been told that he needs a total laryngectomy. What action should this nurse consider to help the patient cope with the loss of his voice?
a. Offer to have a volunteer from a local laryngectomy organization visit the patient.
b. Explain in detail the available vocalization aids and techniques.
c. Explain to the patient what will happen directly after the surgery.
d. Notify the hospital chaplain of the patients needs.
ANS: A
Offering to request a volunteer from the laryngectomy organization is a recommended implementation to reduce the stress of losing the ability to speak. You should consult the patient before making the referral.

DIF: Cognitive Level: Application REF: p. 551 OBJ: 5
TOP: Cancer of the Larynx KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

23. Which nursing concern takes priority in the care of a patient after a laryngectomy?
a. Encouraging nutrition
b. Avoiding infection
c. Establishing a communication system
d. Ensuring adequate fluid intake
ANS: C
Establishing a communication system with the patient who has undergone a laryngectomy is a primary concern.

DIF: Cognitive Level: Application REF: p. 553 OBJ: 5
TOP: Postoperative Laryngectomy KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

24. A patient who had a laryngectomy 3 months earlier returns to the physicians office with the complaint of increasing dyspnea. Which common postlaryngectomy complication should the nurse recognize this complaint as indicating?
a. Hypertrophied stoma
b. Salivary fistula
c. Carotid blowout
d. Tracheal stenosis
ANS: D
Tracheal stenosis causes the otherwise healthy recovering patient who has undergone a laryngectomy to experience increased dyspnea.

DIF: Cognitive Level: Comprehension REF: p. 551 OBJ: 4
TOP: Postoperative Complications of Laryngectomy
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

25. What is one major postoperative difficulty for a patient having a supraglottic laryngectomy?
a. Teaching the patient to use an assistive device to speak
b. Coughing without letting food escape through the tracheostomy
c. Taking care of the tracheostomy, because the patient will always have to have one
d. Teaching the patient to swallow without aspiration
ANS: D
The patient who has had a supraglottic laryngectomy may never be able to swallow correctly, which could easily lead to aspiration pneumonia.

DIF: Cognitive Level: Comprehension REF: p. 555 OBJ: 5
TOP: Supraglottic Laryngectomy KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

MULTIPLE RESPONSE

26. What should the postoperative care of a patient who has had nasal surgery include? (Select all that apply.)
a. Changing the nasal packing when saturated
b. Placing the patient in a semi-Fowler position without a pillow
c. Giving frequent oral hygiene
d. Providing humidification for dry mucous membranes
e. Assessing the back of the throat for bleeding
ANS: B, C, D, E
Only the physician removes the nasal packing. The nurse may change the mustache dressing, however.

DIF: Cognitive Level: Knowledge REF: p. 539 OBJ: 4
TOP: Postnasal Surgery Care KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

27. Which actions should the nurse include in a care plan to effectively assist the patient with a total laryngectomy to maintain airway clearance? (Select all that apply.)
a. Turning, coughing, and deep breathing
b. Placing the patient in a semi-Fowler position
c. Maintaining hydration
d. Attaching a tracheostomy collar
e. Providing a method to communicate
ANS: A, B, C, D
Providing a communication method has high priority, but it is not related to airway clearance.

DIF: Cognitive Level: Comprehension REF: p. 550-554 OBJ: 4
TOP: Maintaining Airway Clearance KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity

COMPLETION

28. A nurse reminds a patient, who is to have a partial laryngectomy, that the temporary tracheostomy that he will have after the original surgery will be closed within _____ days.

ANS:
5
five
The temporary tracheostomy, which is done as part of the partial laryngectomy surgery, is usually closed 5 days after the original surgery.

DIF: Cognitive Level: Comprehension REF: p. 555 OBJ: 4
TOP: Tracheostomy in Partial Laryngectomy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OTHER

29. What should a nurse do when taking a specimen for a throat culture? (Place the appropriate actions in the correct sequence. Separate letters by a comma and space as follows: A, B, C, D.)
A. Depress the tongue with a tongue blade.
B. Place the applicator in a culture tube.
C. Ask the patient to tilt the head back.
D. Swab the back of the throat and tonsils.

ANS:
C, A, D, B
When collecting a specimen for throat culture the patient is asked to tilt the head back, the tongue is depressed with tongue blade, the back of the throat and tonsils are swabbed, and an applicator is placed in a culture tube.

DIF: Cognitive Level: Comprehension REF: p. 533 OBJ: 2
TOP: Throat Culture Specimen KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

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