Question 1

The nurse is concerned that a patient with a fever caused by a bacterial sinus infection is experiencing dehydration.What did the nurse assess in this patient to come to this conclusion? (Select all that apply.)

Accepted Answer

Signs of dehydration include dry skin and mucous membranes,thirst,weakness,and hypotension.D.Full bounding pulses are an indication of overhydration.

Question 2

A patient asks the nurse to explain the difference between the flu and viral rhinitis.What should the nurse include when responding to this question? (Select all that apply.)

Accepted Answer

The onset of symptoms associated with a common cold are slow with little or low-grade fever,runny nose,sore throat,rare headache,and no chest pain (E).Muscle aches are less common than seen with influenza.Influenza symptoms appear suddenly-fever,headache,chest pain,and muscle aches that can be severe are common.Runny nose is less common.C.Antibiotics are used to treat bacterial infections,not the common cold or influenza.

Question 3

The nurse identifies the diagnosis of risk for ineffective airway clearance related to excessive secretions for a patient with an upper airway disorder.Which goal is most appropriate for this health problem?

Accepted Answer

A clear airway is the only goal that addresses the problem.A.Patients need to cough to clear the airway.C.D.Clear sputum and a normal breathing pattern are desirable but do not ensure a clear airway.

Question 4

A patient with a stuffy head is experiencing pain behind and between the eyes.Which sinus area should the nurse identify as causing this patient's health problem?

Accepted Answer

In ethmoid sinusitis,pain occurs between and behind the eyes.A.Pain in the forehead typically indicates frontal sinusitis.C.If a maxillary sinus is affected,the patient will have pain over the cheek and upper teeth.D.There is not a mandibular sinus.

Question 5

A patient awaiting the results of a throat culture is experiencing a severe sore throat.What should the nurse suggest to the patient to ease the throat pain? (Select all that apply.)

Accepted Answer

For throat pain the nurse should suggest throat lozenges,saltwater,or honey and lemon gargles.C.Cold water may or may not ease the throat pain.E.Topical analgesic sprays must be prescribed

Question 6

The nurse is preparing to discharge a patient recovering from a laryngectomy.Which assessment finding should cause the nurse to suggest home care for this patient?

Accepted Answer

A history of noncompliance with medications may predict risk of noncompliance with tracheostomy care-which could risk infection and even death.Follow-up is needed to assess compliance at home.A.C.Migraine headaches and oxygen use at home do not necessarily require skilled home nursing.B.Living with a friend is not an issue unless further assessment reveals a problem.

Question 7

A patient is demonstrating signs of pharyngitis.What should the nurse expect to assess in this patient? (Select all that apply.)

Accepted Answer

The most common symptom of pharyngitis is a sore throat.Some patients may also experience dysphagia.The throat appears red and swollen,and exudate may be present.Exudate usually signifies bacterial infection and may be accompanied by fever,chills,headache,and generalized malaise.D.Extreme thirst is not a symptom of pharyngitis.

Question 8

A patient sees an HCP for symptoms of viral rhinitis.Which treatments should the nurse expect to be prescribed for this patient? (Select all that apply.)

Accepted Answer

Rest,fluids,and decongestants may be helpful.F.Antibiotics are used for bacterial infections.C.Steroids are used for severe inflammation or autoimmune disorders.E.Bronchodilators are used for obstructive airway disease such as asthma.

Question 9

A nurse is providing care for a patient admitted with a temperature of 101.3°F,pulse 98 beats per minute,34 respirations per minute,and blood pressure 106/54 mm Hg.The patient reports chills,nausea,vomiting,diarrhea,and weakness for the past 2 days.Which health care provider (HCP)orders should the nurse complete first?

Accepted Answer

The rapid pulse,respiratory rate,and decreased blood pressure indicate risk for impaired tissue perfusion,and oxygenation is a priority.A.C.D.After the patient's airway is secure,the nurse can then encourage fluids,provide an antipyretic medication,and begin intravenous fluid therapy.

Question 10

A nurse is teaching a patient how to avoid contracting influenza and secondary bacterial infection.Which measures should be included in the instruction? (Select all that apply.)

Accepted Answer

Vaccination,avoiding contact with others who are ill,good hand washing,and avoiding sharing of eating or drinking utensils are the best ways to prevent influenza.C.Unnecessary use of antibiotics can lead to resistant strains of bacteria.D.Vitamin B does not affect risk.

Question 11

The mother of three school-age children asks the nurse what can be done to prevent the spread of a cold between all of the children at the same time.What should the nurse instruct this mother? (Select all that apply.)

Accepted Answer

To prevent the transmission of an infection,the mother should be instructed to wash hands repeatedly throughout the day,avoiding the sharing of eating utensils and drinking cups between the children,and covering the nose and mouth when coughing or sneezing.B.Bed linen does not need to be washed with hot water once a week.D.Participation in sports does not need to be limited during the winter months.

Question 12

For a patient recovering from a tonsillectomy,the physician has ordered an IV normal saline solution at 100 mL per hour.The IV tubing has a drop factor of 15.The nurse should infuse the IV at ____________________ drops per minute.

Accepted Answer

The answer of For a patient recovering from a tonsillectomy,the...

Question 13

A patient is being discharged after nasal surgery.Which should be included in the nurse's instructions for this patient? (Select all that apply.)

Accepted Answer

A cool mist humidifier and fluids help prevent drying.Keeping the head elevated prevents pressure and bleeding.A.B.E.Blowing the nose,warm compresses,and aspirin increase risk of bleeding.

Question 14

A patient is diagnosed with nasal polyps.For which additional health problems should the nurse assess this patient? (Select all that apply.)

Accepted Answer

Some patients with nasal polyps also have asthma and are allergic to aspirin.This is called aspirin triad asthma because the three components often occur together.B.D.E.Nasal polyps are not associated with chronic sinusitis,chronic bronchitis,or an allergy to pet dander.

Quiz 30: Nursing Care of Patients With Upper Respiratory Tract Disorders