Chapter 60: Management of Clients with Upper Airway Disorders Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 60: Management of Clients with Upper Airway Disorders

MULTIPLE CHOICE

1. During a community screening event, the nurse would identify that the client at highest risk for development of laryngeal cancer is

a.

a 30-year-old man who smokes one pack of cigarettes per day.

b.

a 60-year-old woman who smokes occasionally and is easily fatigued.

c.

a 70-year-old man with a 40-year history of alcohol use and heavy smoking.

d.

an 80-year-old man who has a very high intake of caffeinated beverages.

ANS: C

The primary etiologic agent in laryngeal cancer is cigarette smoking. Three of four clients who develop laryngeal cancer have smoked or currently smoke. Alcohol appears to act synergistically with tobacco, increasing the risk of developing a malignant tumor in the upper airway.

DIF: Application/Applying REF: pp. 1551-1552

OBJ: Assessment

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Lifestyle Choices

2. In the preoperative teaching plan for a client scheduled for total laryngectomy and radical neck resection, the nurse would give highest priority to the

a.

client not being able to perform deep-breathing exercises.

b.

client not being able to speak normally again.

c.

endotracheal tube being in place for 2 to 3 days.

d.

insertion of a gastrostomy tube during surgery for feeding.

ANS: B

The greatest problem for the client after laryngectomy is loss of voice. The client should be made aware that without surgery, the voice quality will worsen as the tumor enlarges. In any case, loss of voice constitutes a serious psychological issue.

DIF: Application/Applying REF: pp. 1554-1555

OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Unexpected Body Image Changes

3. The observation that would require an immediate nursing intervention for a client recently returned to the unit following partial laryngectomy is

a.

blood-tinged sputum.

b.

copious respiratory secretions.

c.

difficulty swallowing.

d.

pulsating tracheostomy tube.

ANS: D

A pulsating tracheostomy tube may indicate that the tip of the tube is resting on the innominate artery and may cause injury to the artery, resulting in hemorrhage.

DIF: Analysis/Analyzing REF: p. 1555 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

4. In planning postoperative nursing care for a client who has undergone radical neck dissection and total laryngectomy, the nurse would give priority to the fact that

a.

esophageal speech is relatively difficult to learn and takes practice.

b.

prognosis after treatment is moderate, depending on findings.

c.

the stoma should never be covered after this type of surgery.

d.

there is a radical change in appearance as a result of this type of surgery.

ANS: D

Surgical management of laryngeal tumors often includes neck dissection. Radical neck dissection is the removal of lymphatic drainage channels and nodes, sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and submandibular area. The radical approach to surgery results in a drastic change in appearance. Esophageal speech is not difficult to learn. Laryngeal cancer is potentially curable if caught early enough. Clients often learn to camouflage their stomas by covering them with articles of clothing, such as scarves or turtleneck sweaters.

DIF: Application/Applying REF: p. 1555 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Unexpected Body Image Changes

5. A client recently had a total laryngectomy and plans to use an artificial larynx for speech. The common problem the nurse would address regarding the artificial larynx is that

a.

it is a device that is difficult to use.

b.

it has a masculine-sounding voice quality.

c.

it has a monotone speech quality.

d.

it causes neck discomfort.

ANS: C

The speech quality is monotone and mechanical sounding but intelligible. The artificial larynx can be used starting about 3-4 days after surgery.

DIF: Comprehension/Understanding REF: p. 1558 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

6. The priority nursing intervention for a client experiencing a laryngospasm would be

a.

administering 100% oxygen.

b.

calling the resuscitation team.

c.

positioning the client in high-Fowler position.

d.

starting in IV with a large-bore catheter.

ANS: A

Management is directed at reestablishing the airway as quickly and efficiently as possible. The nurse should administer 100% oxygen and then call for assistance. Oxygen is continued until the spasms stop and the client is breathing easily. The client may need paralysis with neuromuscular blocking agents and mechanical ventilation.

DIF: Application/Applying REF: p. 1566 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

7. When a friend comes to the nurses apartment to seek help to stop the bleeding from a broken nose, the nurse would attempt to convince the friend to seek treatment in the emergency department primarily because

a.

cosmetic results are poor when treatment is delayed.

b.

general anesthesia may be needed to locate the bleeding vessels.

c.

it will be very difficult to stop the bleeding if the nose is fractured.

d.

the nose cannot be set for 2 to 3 days if edema develops.

ANS: D

If a nasal fracture occurs, immediate medical management is advised. Within several hours of nasal injury, severe edema may occur, which causes difficulty in reducing the fracture.

DIF: Application/Applying REF: p. 1567 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

8. After a posterior nasal pack is inserted by the physician, the client is very anxious and states, I dont feel like Im breathing right. The immediate intervention the nurse would initiate is

a.

collect a specimen for arterial blood gases (ABGs).

b.

cut the pack strings and pull the packing out.

c.

inspect the clients oral cavity using a flashlight.

d.

reassure the client that this is normal discomfort.

ANS: C

The nurse should inspect the oral cavity for the presence of blood, soft palate necrosis, and proper placement of the posterior plug. If the posterior plug is visible, the physician is notified for readjustment of the packing. Having posterior packing is very uncomfortable and clients may need both analgesics and anxiolytics to tolerate it. But before medicating the client, a thorough assessment is warranted.

DIF: Application/Applying REF: p. 1564 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

9. A nurse is teaching a client with a new tracheostomy self-care measures and evaluates that teaching goals have been met when the client says

a.

I can shower if I am careful not to get water into the stoma.

b.

I dont see why I should quit smoking now; what more could happen?

c.

Stoma covers arent used because they can lead to suffocation.

d.

When my tube comes out I can go swimming again.

ANS: A

Showers and tub baths are allowed as long as water does not enter the stoma. Quitting smoking, even at this late date still helps preserve lung function and should be encouraged. Stoma covers or bibs are often used to hide the stoma. Swimming and other water sports are prohibited.

DIF: Evaluation/Evaluating REF: p. 1560 OBJ: Evaluation

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

10. For an elderly client who has a posterior nasal plug and anterior nasal packing in place to control an episode of severe epistaxis, the priority assessment for the nurse would be assessing for

a.

continuing nasal pain.

b.

dislodged packing.

c.

presence of hypoxia.

d.

swallowing blood.

ANS: C

Clients with posterior plugs and anterior nasal packing are admitted to the hospital and monitored closely for hypoxia. Posterior packing can affect both level of consciousness and respiratory status, especially in the elderly client.

DIF: Analysis/Analyzing REF: p. 1564 OBJ: Assessment

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Age Related Differences

11. Which intervention would probably help most when teaching a client to speak again after a laryngectomy?

a.

Give the client contact information so speech therapy can continue at home.

b.

Help the client and family understand that this is a frustrating experience.

c.

Make sure the client has a supply of paper and pens.

d.

Obtain several different speaking aids for the client to try at home.

ANS: B

The client needs to be encouraged to continue speech therapy until speech is relearned. This is a time-consuming and frustrating experience for both the client and others. The nurse can decrease stress and frustration by explaining the frustrating nature of this experience to the client/family.

DIF: Comprehension/Understanding REF: p. 1560 OBJ: Intervention

MSC: Psychosocial Integrity Coping and Adaptation-Coping Mechanisms

12. For a client who has undergone functional endoscopic sinus surgery (FESS) as part of the surgical management of sinusitis, the nurse would instruct the client

a.

Dont blow your nose for 1 week.

b.

Eat only semi-solid foods.

c.

Lean forward when eating.

d.

Limit the amount of fluids you drink.

ANS: A

FESS clients should avoid blowing the nose for 7 days after surgery. They should sniff backward or spit, not blow. Clients should increase their fluid intake.

DIF: Application/Applying REF: p. 1563 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

13. The nurse would explain to a client that laser surgery to remove laryngeal tumors has the major benefit of

a.

a usable voice.

b.

complete cure.

c.

minimal blood loss.

d.

reduced edema.

ANS: A

Laser excision of laryngeal tumors usually results in a usable voice after surgery. Sometimes laser surgery is combined with radiation for better outcomes.

DIF: Comprehension/Understanding REF: p. 1554 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

14. A nurse is conducting health seminars in the community. Besides instructing the audience to not abuse alcohol and to stop smoking, other preventive measures the nurse could suggest include

a.

exercising at least 30 minutes on most days of the week.

b.

increasing daily fiber intake to 20-30 grams a day.

c.

limiting intake of saturated fats and trans fats.

d.

wearing respiratory protective equipment if exposed to asbestos.

ANS: D

Smoking and alcohol abuse are major risk factors for developing laryngeal cancer. Other risks include exposure to asbestos, wood dust, mustard gas, and petroleum products and inhalation of other noxious fumes.

DIF: Comprehension/Understanding REF: pp. 1551-1552

OBJ: Assessment MSC: Physiological Integrity

15. A client has frequent bouts of laryngitis. When assessing the client the nurse should specifically ask questions regarding the presence of

a.

a family history of idiopathic hoarseness.

b.

frequent upper respiratory tract infections.

c.

gastroesophageal reflux disorder.

d.

a history of stomach cancer.

ANS: C

In GERD, the cardiac sphincter relaxes, allowing gastric acid to enter the esophagus. The secretions may be allowed to enter the larynx, causing chemical irritation. Chronic irritation can lead to bouts of laryngitis. The other three options are not related.

DIF: Application/Applying REF: p. 1565 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

16. A client is in the recovery room after surgical removal of nasal polyps. The nurse notices the client is swallowing frequently. The most appropriate action by the nurse is to

a.

assess the clients mouth for blood.

b.

continue to monitor and assess the client.

c.

notify the physician immediately.

d.

turn the client on the left side.

ANS: A

After surgery to remove nasal polyps, the client will have nasal packing. Because the packing will simply absorb any anterior bleeding, it is necessary to assess for posterior bleeding. The only manifestation may be excessive swallowing. The nurse should assess for posterior bleeding and call the surgeon.

DIF: Application/Applying REF: p. 1567 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

17. A nurse is assessing a client who complains of hoarseness, frequent choking, and the feeling of something stuck in the throat. The nurse should plan to include teaching on the diagnostic tests for

a.

a glottic tumor.

b.

laryngeal paralysis.

c.

tracheal deviation.

d.

vocal cord disruption.

ANS: A

Other manifestations include pain in the throat, especially when swallowing, neck masses, or pain radiating to the ear by way of the glossopharyngeal and vagus nerves.

DIF: Application/Applying REF: pp. 1552-1553

OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

18. The measure that would best aid the nurse in removing heavy, tenacious secretions during suctioning is

a.

encouraging frequent coughing and deep breathing.

b.

employing postural drainage before suctioning.

c.

hyperinflating the lungs before suctioning.

d.

instilling sterile saline directly into the trachea.

ANS: D

If tracheal secretions are thick and not easily removed, the nurse should directly instill 3 ml of sterile normal saline into the trachea. The saline reduces the viscosity of secretions for easier removal. This is not a routine intervention; however, if it is needed, the nurse should collaborate with the respiratory therapist to ensure the client is receiving adequate humidity and should assess the client for adequate hydration. These measures will help prevent the client from having heavy secretions.

DIF: Application/Applying REF: pp. 1548-1549

OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

19. The nurse explaining the pieces of a tracheostomy to a client would note that the portion of the tracheostomy apparatus used to round the end of the tube for insertion is the

a.

flange.

b.

inner cannula.

c.

obturator.

d.

pilot tube.

ANS: C

The obturator is placed into the outer tube before insertion. Its rounded tip smoothes the end of the cannula and facilitates nontraumatic insertion of the tube into the stoma.

DIF: Comprehension/Understanding REF: p. 1542 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Managing Equipment

20. A client has a fenestrated tracheostomy tube in place. A tracheostomy plug will be used to allow the client to talk. The intervention by the nurse that would be essential before inserting the plug is

a.

alerting the client to a new system of communication.

b.

deflating the cuff on the tracheostomy tube.

c.

evaluating the clients tidal volume.

d.

positioning the client to facilitate air flow.

ANS: B

A cuffed tracheostomy tube is always deflated before using a talking tracheostomy adapter. Cuff inflation prevents exhalation, causing suffocation.

DIF: Application/Applying REF: p. 1544 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

21. The spouse of a client who is receiving mechanical ventilation via tracheostomy asks why his wife cannot have a tracheostomy button. The nurses most informative response would be

a.

A button cannot be used with a ventilator.

b.

Buttons make the work of breathing harder.

c.

Suctioning cant be done with buttons.

d.

That would decrease your wifes oxygenation.

ANS: A

A button cannot be used with a ventilator. It is sometimes used during weaning. It replaces a standard tracheostomy tube for clients with retained secretions who do not require ventilatory assistance.

DIF: Comprehension/Understanding REF: p. 1544 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

22. A client with a Jackson metal tracheostomy tube has been admitted with pneumonia and dyspnea. The nurse would make arrangements to have supplies on hand to compensate for the fact that this type of tracheostomy tube

a.

does not have an inner cannula.

b.

has a high-pressure cuff.

c.

has no respirator adapter.

d.

is very short.

ANS: C

Because metal tubes do not have a standard 15-mm adapter, rapid adaptation to respiratory or anesthesia equipment is impossible unless a specific adapter is available. Since this client is at high risk for worsening respiratory problems, the astute nurse would ensure that an adapter for ventilator use is nearby.

DIF: Analysis/Analyzing REF: p. 1544 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

23. When a client coughs violently and the tracheostomy tube falls out, the client becomes dyspneic and the nurse attempts to reinsert the tracheostomy tube over the next 60 seconds but is unable to do so. The nurses next action would be

a.

call a code.

b.

perform a cricoidectomy.

c.

place a finger in the stoma.

d.

start oxygen via nasal prongs.

ANS: A

If the tracheostomy tube cannot be reinserted in 1 minute, the nurse should call a code for respiratory arrest. Unless the client is breathing adequately, an emergency cricoidectomy will be necessary. See the steps in Box 60-2 for the correct procedure.

DIF: Application/Applying REF: p. 1546 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

24. A client is trying unsuccessfully to clear the airway with a cough. The measure the nurse would suggest to help the client cough more effectively is

a.

cough while leaning forward.

b.

drink milk to coat the throat.

c.

insert a large-lumen suction catheter before coughing.

d.

place a clean finger over the tracheostomy tube and cough.

ANS: D

When the clients condition is stabilized sufficiently, coughing may be enhanced by having the client place a finger over the tracheostomy tube opening while attempting to cough.

DIF: Application/Applying REF: p. 1548 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

25. When feeding a client with a tracheostomy, the nurse would

a.

follow each spoon of food with liquid.

b.

have the client in an upright sitting position.

c.

inflate the cuff before the meal.

d.

thin the food to liquid consistency.

ANS: B

If a client is awake and has an intact gag reflex after a tracheostomy, oral feeding can be attempted in conjunction with a speech therapist. Assess for a fistula if the client had a cuffed endotracheal tube before the tracheostomy. Have the client sit upright and give foods that are the consistency of pudding.

DIF: Application/Applying REF: p. 1550 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

26. A neighbor tells a nurse that s/he has been experiencing hoarseness for over 3 weeks. The nurse should advise the client to see a doctor for

a.

a prescription for antacids.

b.

possible laryngeal cancer.

c.

throat cultures and antibiotics.

d.

vocal cord paralysis.

ANS: B

GERD and throat infections can certainly cause hoarseness, but hoarseness that lasts for more than 2 weeks is suspicious for laryngeal cancer. Vocal cord paralysis could cause a hoarseness with a breathy quality to the voice.

DIF: Application/Applying REF: p. 1552 OBJ: Intervention

MSC: Physiological Integrity

27. Noting the need to use 8 ml rather than 5 ml to inflate the tracheostomy cuff sufficiently, the nurse would

a.

ask the client to swallow, and then cough.

b.

completely deflate the cuff to relieve the dilation.

c.

notify the physician to have an x-ray film obtained.

d.

replace the entire tracheostomy tube with a larger size.

ANS: C

When the nurse notes the need for greater amount of air in the cuff to create an effective seal, the nurse should report this to the physician so that a confirming x-ray film for tracheal dilation can be obtained.

DIF: Application/Applying REF: p. 1546 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Unexpected Response to Therapies

28. During a direct visual examination of the larynx, the best intervention the nurse could offer is to

a.

give the client anti-anxiety medication.

b.

help the client hold still.

c.

hold the clients hand.

d.

tell the client to pant like a puppy.

ANS: D

Panting will decrease the gagging sensation that occurs during the examination.

DIF: Application/Applying REF: p. 1553 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

MULTIPLE RESPONSE

1. A busy nurse in the ICU wishes to delegate aspects of respiratory care to an unlicensed assistive personnel (UAP). Which of the following actions can the nurse delegate? (Select all that apply.)

a.

Measuring and recording oxygen saturations

b.

Setting up oxygen delivery and suction equipment

c.

Suctioning secretions of a client with a long-standing tracheostomy

d.

Teaching the client how to cough with a tracheostomy

e.

Verifying that the correct amount of oxygen is being delivered

ANS: A, B, C

A UAP can do the items in options a, b, and c. Teaching is always the responsibility of the nurse; however, the UAP can reinforce the teaching once the nurse has assessed that the client and family understand what has been presented. Verifying that the oxygen is set to deliver the correct flow rate is also a nurses responsibility.

DIF: Application/Applying REF: p. 1548 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Delegation

2. The nurse working with a client who has acute sinusitis plans to teach the client about the routinely-used treatments for this condition, which include (Select all that apply)

a.

antibiotics.

b.

antihistamines.

c.

mucolytic agents.

d.

oral alpha-adrenergic vasoconstrictors.

ANS: B, C, D

Antibiotics, once the mainstay of treatment for sinusitis, are no longer used routinely because many sinus infections are viral. Routine treatments include antihistamines for clients who have acute sinusitis in the setting of allergies, mucolytic agents such as guaifenesin, and oral alpha-adrenergic vasoconstrictors such as pseudoephedrine.

DIF: Application/Applying REF: p. 1562 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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