Question 1

The nurse is obtaining a health history from a 67-year-old patient with a 40 pack-year smoking history, complaints of hoarseness and tightness in the throat, and difficulty swallowing. Which question is most important for the nurse to ask?

Accepted Answer

Prolonged alcohol use is associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Use of chewing tobacco or snuff is associated with oral cancers rather than throat cancers. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but this is not the priority assessment to obtain at this time. Streptococcal throat infections may also cause these clinical manifestations, but patients will also complain of pain and fever.

Question 2

The nurse notes all of these findings in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider?

Accepted Answer

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 symptoms of influenza and are treated with supportive care measures such as OTC pain relievers and increased fluid intake.

Question 3

A spontaneously breathing patient who has a cuffed tracheostomy tube in place has new orders for speech therapy and a soft diet. To evaluate whether the patient can safely have the cuff deflated to promote speaking and make swallowing easier, the nurse deflates the cuff and then

Accepted Answer

Assessing the ability of the patient to drink a colored fluid, such as grape juice, will provide evidence that the patient will not aspirate. Even if the patient is able to talk, aspiration may occur. Because the patient is already breathing spontaneously, deflating the cuff would not cause respiratory distress. Although aspiration may lead to complications such as pneumonia, the absence of lung crackles immediately after drinking a clear liquid is not a clear indicator that aspiration has not occurred.

Question 4

A patient returns from surgery with a tracheostomy tube after a total laryngectomy and radical neck dissection. In caring for the patient during the first 24 hours after surgery, the priority nursing action is to

Accepted Answer

The most important goals post-tracheotomy are to maintain the airway and ensure adequate oxygenation. Assessment of the airway and breath sounds is the priority action. Maintenance of the tracheostomy ties, cleaning the inner cannula, and checking for bleeding are also appropriate nursing actions but are not of as high a priority.

Question 5

A patient is discharged from the hospital with a tracheostomy tube for long-term airway management. The nurse determines that teaching related to care of the tracheostomy has been effective when the patient says,

Accepted Answer

It takes several months for the formation of a fully healed tract, so the patient is taught to leave the tracheostomy tube in place for several months. Clean (rather than sterile) gloves and catheters are used for suctioning at home to decrease expense. Semisoft foods, rather than liquids, are the easiest to swallow. Water should not be instilled into the tracheostomy; thick secretions may indicate the need for more fluid intake or humidification.

Question 6

An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene?

Accepted Answer

Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other student actions do not require intervention by the RN. Although the patient may not need 2 minutes of preoxygenation, this would not be unsafe; 10 seconds of suction is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube.

Question 7

When the nurse removes a nasogastric (NG) tube that has been in place for 7 days, the patient develops a nosebleed. To control the bleeding, the nurse should initially

Accepted Answer

The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. The patient should be sitting and leaning forward. Ice compresses may be helpful in decreasing bleeding but is not the most appropriate initial action. If the bleeding persists, the nares may be packed with ribbon gauze by the health care provider.

Question 8

A patient who has sleep apnea and has been using CPAP for 2 weeks returns to the sleep clinic and tells the nurse, "My sleep has not improved at all." Which response by the nurse is most appropriate?

Accepted Answer

Although CPAP is very effective in improving sleep quality in patients with sleep apnea, many patients are noncompliant with this therapy. The nurse should be sure that the patient is actually using the CPAP. When CPAP is used, the effects on sleep quality are immediate. Surgery may be an appropriate therapy for the patient, but suggesting surgery would not be an appropriate first action by the nurse in this situation. CPAP using higher pressures will make it more difficult for the patient to exhale and is likely to decrease compliance with therapy.

Question 9

A patient with a tracheostomy is to use a fenestrated tracheostomy tube to provide for speech. Which of the following interventions will be included in the plan of care?

Accepted Answer

Because the cuff is deflated when using a fenestrated tube, the patient's 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 patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords.

Question 10

The nurse is reviewing the charts for these patients who are scheduled in October for their yearly physical examinations. The nurse will plan on administration of the influenza vaccine injection to the

Accepted Answer

It is recommended that patients who are immune compromised receive yearly influenza vaccinations. The corticosteroid use by the 30-year-old increases the risk for infection. The other three individuals are not at increased risk for influenza. Current guidelines suggest that healthy individuals between ages 5 and 49 receive intranasal immunization with live, attenuated influenza vaccine (FluMist).

Question 11

When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow, it is important to

Accepted Answer

The patient's mouth and trachea should be suctioned before the cuff is deflated to prevent aspiration of oral secretions. The amount of air needed to inflate the cuff varies and is adjusted by measuring cuff pressure or using the minimal leak technique, not by measuring the volume of air removed from the cuff. The cuff is deflated during patient exhalation so that secretions will be forced into the mouth rather than aspirated. There is no need to clean the inner cannula before cuff deflation.

Question 12

A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective?

Accepted Answer

Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not effect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Use of lotions on skin being radiated is avoided.

Question 13

A patient has undergone a rhinoplasty to correct nasal deformities resulting from trauma during an automobile accident. The nursing intervention that is most appropriate postoperatively is to

Accepted Answer

Maintaining the head in an elevated position will decrease the amount of nasal swelling. Although acetaminophen may be appropriate, aspirin and the NSAIDs will increase the risk for postoperative bleeding. The nasal packing is usually removed the next day. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result.

Question 14

A nursing diagnosis of body image disturbance related to loss of control of personal care is identified for a patient with a total laryngectomy and radical neck dissection. The nurse evaluates that an expected outcome for the problem has been met when the patient

Accepted Answer

Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and the body image disturbance is at least partially resolved. Allowing the spouse to provide care, allowing family members to visit, and wearing clothing that masks the body changes are outcomes that do not directly address this nursing diagnosis.

Question 15

When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to

Accepted Answer

Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal capillaries. A firm pilot balloon indicates that the cuff is inflated but does not assess for overinflation. A health care provider's order is not required to determine safe cuff pressure. A minimal leak technique is an alternate means for cuff inflation, but this technique does allow a small air leak around the cuff and increases the risk for aspiration.

Question 16

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "How will I talk after the surgery?" The best response by the nurse is,

Accepted Answer

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.

Question 17

When teaching the patient with allergic rhinitis about management of the condition, the nurse explains that

Accepted Answer

The most important intervention is to assist the patient to identify and avoid potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Nonsedating antihistamines are available OTC.

Question 18

A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. The nurse's first action should be to

Accepted Answer

The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's 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. The patient should be placed in a semi-Fowler's position, but the neck should remain in a neutral position.

Question 19

After discussing care of upper respiratory infections (URI) and prevention of secondary infections with a patient who has a URI, the nurse determines that additional teaching is needed when the patient says

Accepted Answer

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.

Question 20

A patient who has been diagnosed with sleep apnea has CPAP ordered. Which of these nursing actions in the plan of care can the RN delegate to a nursing assistant?

Accepted Answer

Reminding a patient about previously taught self-care activities is within the education level and scope of practice for a nursing assistant. Assessment and teaching are skills that require higher-level nursing education and scope of practice.

Quiz 27: Nursing Management: Upper Respiratory Problems