Question 1

Which of these patients in the respiratory disease clinic should the nurse assess first?&#10;A) A 23-year-old, complaining of a sore throat, who has a &#34;hot potato&#34; voice&#10;B) A 34-year-old who has a &#34;scratchy throat&#34; and a positive rapid strep antigen test&#10;C) A 55-year-old who is receiving radiation for throat cancer and has severe fatigue&#10;D) A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed

Accepted Answer

The patient's clinical manifestation of a "hot potato" voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems.

Question 2

After discussing management of upper respiratory infections (URI) with a patient who has acute viral rhinitis, the nurse determines that additional teaching is needed when the patient says&#10;A) &#34;I can take acetaminophen (Tylenol) to treat discomfort.&#34;&#10;B) &#34;I will drink lots of juices and other fluids to stay hydrated.&#34;&#10;C) &#34;I can use my nasal decongestant spray until the congestion is all gone.&#34;&#10;D) &#34;I will watch for changes in nasal secretions or the sputum that I cough up.&#34;

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 3

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?&#10;A) The student preoxygenates the patient for 1 minute before suctioning.&#10;B) The student puts on clean gloves and uses a sterile catheter to suction.&#10;C) The student inserts the catheter about 5 inches into the tracheostomy tube.&#10;D) The student applies suction for 10 seconds while withdrawing the catheter.

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 1 minute of preoxygenation, this would not be unsafe. Suctioning for 10 seconds is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube, but 5 inches would be appropriate for most adult patients.

Question 4

The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to treat a nosebleed. Which of the following assessment findings will require the most immediate action by the nurse?

A) The oxygen saturation is 89%.
B) The nose appears red and swollen.
C) The patient's temperature is 100.1° F ( 37.8° C ).
D) The patient complains of level 7 ( 0 to 10 scale ) pain.

Accepted Answer

Older patients with nasal packing are at risk of aspiration or airway obstruction. An O₂ saturation of 89% should alert the nurse to assess further for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the fall in O₂ saturation.

Question 5

A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?&#10;A) Insert the obturator and attempt to reinsert the tracheostomy tube.&#10;B) Position the patient in an upright position with the neck extended.&#10;C) Assess the patient's oxygen saturation and notify the health care provider.&#10;D) Ventilate the patient with a manual bag until the health care provider arrives.

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 if reinsertion of the tracheostomy tube is not successful.

Question 6

The nurse obtains the following assessment data in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider?&#10;A) Fever of 100.4&#176; F ( 38&#176; C )&#10;B) Diffuse crackles in the lungs&#10;C) Sore throat and frequent cough&#10;D) Myalgia and persistent headache

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 over-the-counter (OTC) pain relievers and increased fluid intake.

Question 7

When teaching the patient with allergic rhinitis about management of the condition, the nurse explains that&#10;A) over-the-counter ( OTC ) antihistamines cause sedation, so prescription antihistamines are usually ordered.&#10;B) corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.&#10;C) use of oral antihistamines for a few weeks before the allergy season may prevent reactions.&#10;D) identification and avoidance of environmental triggers are the best way to avoid symptoms.

Accepted Answer

The most important intervention is to assist the patient in identifying and avoiding 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 8

The nurse is caring for a spontaneously breathing patient who has a tracheostomy. To determine that the patient can protect the airway when eating without having the tracheostomy cuff inflated, the nurse will deflate the cuff and

A) ask the patient to say a few sentences.
B) monitor for signs of respiratory distress.
C) have the patient drink a small amount of grape juice and observe for coughing.
D) auscultate the lungs for crackles after having the patient take a few sips of water.

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. Crackles are not present immediately after aspiration, since the inflammatory process takes time to occur.

Question 9

After a patient has undergone a rhinoplasty, which nursing intervention will be included in the plan of care?&#10;A) Educate the patient about how to safely remove and reapply nasal packing.&#10;B) Reassure the patient that the nose will look normal when the swelling subsides.&#10;C) Instruct the patient to keep the head elevated for 48 hours to minimize swelling and pain.&#10;D) Teach the patient to use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control.

Accepted Answer

Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not be taught to remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result.

Question 10

When the nurse is caring for a patient who has had a total laryngectomy and radical neck dissection during the first 24 hours after surgery, what is the priority nursing action?&#10;A) Monitor for bleeding.&#10;B) Assess breath sounds.&#10;C) Clean the inner cannula every 8 hours.&#10;D) Avoid changing the tracheostomy ties.

Accepted Answer

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

Question 11

When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to&#10;A) check the pilot balloon after inflation to ensure that it is firm.&#10;B) use a manometer to ensure cuff pressure is at an appropriate level.&#10;C) check the amount of cuff pressure ordered by the health care provider.&#10;D) fill the balloon until minimal air leakage around the cuff is auscultated.

Accepted Answer

The answer of When inflating the cuff on a tracheostomy...

Question 12

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that the problem identified in this nursing diagnosis is resolving?

A) The patient lets the spouse provide tracheostomy care.
B) The patient allows the nurse to suction the tracheostomy.
C) The patient asks how to clean the tracheostomy stoma and tube.
D) The patient uses a communication board to request "No Visitors."

Accepted Answer

The answer of A patient who had a total laryngectomy...

Question 13

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action will be included in the plan of care?&#10;A) Leave the tracheostomy inner cannula inserted at all times.&#10;B) Place the decannulation cap in the tube before cuff deflation.&#10;C) Assess the ability to swallow before using the fenestrated tube.&#10;D) Inflate the tracheostomy cuff during use of the fenestrated tube.

Accepted Answer

The answer of A patient with a tracheostomy has a...

Question 14

A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective?&#10;A) &#34;I will need to buy a water bottle to carry with me.&#34;&#10;B) &#34;I should not use any lotions on my neck and throat.&#34;&#10;C) &#34;Until the radiation is complete, I may have diarrhea.&#34;&#10;D) &#34;Alcohol-based mouthwashes will help clean oral ulcers.&#34;

Accepted Answer

The answer of A patient with laryngeal cancer has received...

Question 15

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, &#34;How will I talk after the surgery?&#34; The best response by the nurse is,&#10;A) &#34;You will breathe through a permanent opening in your neck, but you will not be able to communicate orally.&#34;&#10;B) &#34;You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed.&#34;&#10;C) &#34;You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally.&#34;&#10;D) &#34;You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.&#34;

Accepted Answer

The answer of A patient scheduled for a total laryngectomy...

Question 16

Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN/LVN who is caring for a patient with a permanent tracheostomy?&#10;A) Assessing the patient's risk for aspiration&#10;B) Suctioning the tracheostomy when needed&#10;C) Educating the patient about self-care of the tracheostomy&#10;D) Determining the need for replacement of the tracheostomy tube

Accepted Answer

The answer of Which of these nursing actions can the...

Question 17

When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow, it is important to&#10;A) clean the inner cannula of the tracheostomy tube before deflation.&#10;B) deflate the cuff during the inhalation phase of the respiratory cycle.&#10;C) suction the patient's mouth and trachea before deflation of the cuff.&#10;D) insert exactly the same volume of air into the cuff during reinflation.

Accepted Answer

The answer of When the nurse is deflating the cuff...

Question 18

After completing discharge instructions for a patient with a total laryngectomy, the nurse determines that additional instruction is needed when the patient says,&#10;A) &#34;I must keep the stoma covered with a loose sterile dressing at all times.&#34;&#10;B) &#34;I can participate in most of my prior fitness activities except swimming.&#34;&#10;C) &#34;I should wear a Medic Alert bracelet that identifies me as a neck breather.&#34;&#10;D) &#34;I need to be sure that I have smoke and carbon monoxide detectors installed.&#34;

Accepted Answer

The answer of After completing discharge instructions for a patient...

Question 19

Which action should the nurse take first when a patient develops a nosebleed?&#10;A) Pack both nares tightly with 1/2-inch ribbon gauze.&#10;B) Pinch the lower portion of the nose for 10 minutes.&#10;C) Prepare supplies that will be needed for cauterization.&#10;D) Apply ice compresses over the patient's nose and cheeks.

Accepted Answer

The answer of Which action should the nurse take first...

Question 20

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?

A) "How much alcohol do you drink in an average week?"
B) "Do you have a family history of head or neck cancer?"
C) "Have you had frequent streptococcal throat infections?"
D) "Do you use antihistamines for upper airway congestion?"

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Accepted Answer

The answer of The nurse is obtaining a health history...

Question 21

The nurse enters the room of a patient who has just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? Put a comma and space between each solve choice (a, b, c, d, etc.) ____________________

A) The nasogastric ( NG ) tube is disconnected from suction and clamped off.
B) The patient is in a side-lying position with the head of the bed flat.
C) The Hemovac in the neck incision contains 200 mL of bloody drainage.
D) The patient is coughing blood-tinged secretions from the tracheostomy.

Accepted Answer

The answer of The nurse enters the room of a...

Question 22

The nurse is reviewing the charts for five patients who are scheduled for their yearly physical examinations in October. Which of the following patients will require the inactivated influenza vaccination (select all that apply)?

A) A 56-year-old patient who is allergic to eggs
B) A 36-year-old female patient who is pregnant
C) A 42-year-old patient who has a 15 pack-year smoking history
D) A 30-year-old patient who takes corticosteroids for rheumatoid arthritis
E) A 24-year-old patient who has allergies to penicillin and the cephalosporins

Accepted Answer

The answer of The nurse is reviewing the charts for...

Question 23

The teaching plan for a patient with acute sinusitis will need to include which of the following interventions (select all that apply)?&#10;A) Taking a hot shower will increase sinus drainage and decrease pain.&#10;B) Over-the-counter ( OTC ) antihistamines can be used to relieve congestion and inflammation.&#10;C) Saline nasal spray can be made at home and used to wash out secretions.&#10;D) Blowing the nose forcefully should be avoided to decrease nosebleed risk.&#10;E) You will be more comfortable if you keep your head in an upright position.&#10;F) None of above

Accepted Answer

The answer of The teaching plan for a patient with...

Deck 27: Nursing Management: Upper Respiratory Problems