Deck 23: Nursing Management: Upper Respiratory Problems

Question 1

The nurse is caring for a hospitalized older patient who has nasal packing in place to treat a nosebleed.Which assessment finding 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 8 (0 to 10 scale) pain.

Answer 1

The oxygen saturation is 89%.

Question 2

A patient arrives in the ear,nose,and throat clinic complaining of a piece of tissue being "stuck up my nose" and with foul-smelling nasal drainage from the right nare.Which action should the nurse take first?

A) Notify the clinic health care provider.
B) Obtain aerobic culture specimens of the drainage.
C) Ask the patient about how the cotton got into the nose.
D) Have the patient occlude the left nare and blow the nose.

Answer 2

Have the patient occlude the left nare and blow the nose.

Question 3

The nurse plans to teach a patient how to manage allergic rhinitis.Which information should the nurse include in the teaching plan?

A) Hand washing is the primary way to prevent spreading the condition to others.
B) Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions.
C) Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.
D) Identification and avoidance of environmental triggers are the best way to avoid symptoms.

Answer 3

Identification and avoidance of environmental triggers are the best way to avoid symptoms.

Question 4

A 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?

A) Monitor for bleeding.
B) Maintain adequate IV fluid intake.
C) Suction tracheostomy every eight hours.
D) Keep the patient in semi-Fowler's position.

Question 5

The nurse completes discharge instructions for a patient with a total laryngectomy.Which statement by the patient indicates that additional instruction is needed?

A) "I must keep the stoma covered with an occlusive dressing at all times."
B) "I can participate in most of my prior fitness activities except swimming."
C) "I should wear a Medic-Alert bracelet that identifies me as a neck breather."
D) "I need to be sure that I have smoke and carbon monoxide detectors installed."

Question 6

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse,"Will I be able to talk normally after surgery?" What is the best response by the nurse?

A) "You will breathe through a permanent opening in your neck, but you will not be able to communicate orally."
B) "You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed."
C) "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."
D) "You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration."

Question 7

Which nursing action could the registered nurse (RN)working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN)caring for a patient with a permanent tracheostomy?

A) Assess the patient's risk for aspiration.
B) Suction the tracheostomy when needed.
C) Teach the patient about self-care of the tracheostomy.
D) Determine the need for replacement of the tracheostomy tube.

Question 8

The nurse obtains the following assessment data on an older patient who has influenza.Which information will be most important for the nurse to communicate to the health care provider?

A) Fever of 100.4° F (38° C)
B) Diffuse crackles in the lungs
C) Sore throat and frequent cough
D) Myalgia and persistent headache

Question 9

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube.Which action should the nurse include in the plan of care in collaboration with the speech therapist?

A) Leave the tracheostomy inner cannula inserted at all times.
B) Place the decannulation cap in the tube before cuff deflation.
C) Assess the ability to swallow before using the fenestrated tube.
D) Inflate the tracheostomy cuff during use of the fenestrated tube.

Question 10

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 this identified problem 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."

Question 11

The nurse discusses management of upper respiratory infections (URI)with a patient who has acute sinusitis.Which statement by the patient indicates that additional teaching is needed?

A) "I can take acetaminophen (Tylenol) to treat my discomfort."
B) "I will drink lots of juices and other fluids to stay well hydrated."
C) "I can use my nasal decongestant spray until the congestion is all gone."
D) "I will watch for changes in nasal secretions or the sputum that I cough up."

Question 12

Which action should the nurse take first when a patient develops a nosebleed?

A) Pinch the lower portion of the nose for 10 minutes.
B) Pack the affected nare tightly with an epistaxis balloon.
C) Obtain silver nitrate that will be needed for cauterization.
D) Apply ice compresses over the patient's nose and cheeks.

Question 13

Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx?

A) "I will need to buy a water bottle to carry with me."
B) "I should not use any lotions on my neck and throat."
C) "Until the radiation is complete, I may have diarrhea."
D) "Alcohol-based mouthwashes will help clean oral ulcers."

Question 14

A nurse obtains a health history from a patient who has a 35 pack-year smoking history.The patient complains 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?"

Question 15

The nurse teaches a patient about discharge instructions after a rhinoplasty.Which statement,if made by the patient,indicates that the teaching was successful?

A) "I can take 800 mg ibuprofen for pain control."
B) "I will safely remove and reapply nasal packing daily."
C) "My nose will look normal after 24 hours when the swelling goes away."
D) "I will keep my head elevated for 48 hours to minimize swelling and pain."

Question 16

Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube.Which action should the nurse take first?

A) Cover stoma with sterile gauze and ventilate through stoma.
B) Attempt to reinsert the tracheostomy tube with the obturator in place.
C) Assess the patient's oxygen saturation and notify the health care provider.
D) Ventilate the patient with a manual bag and face mask until the health care provider arrives.

Question 17

After being hit by a baseball,a patient arrives in the emergency department with a possible nasal fracture.Which finding by the nurse is most important to report to the health care provider?

A) Clear nasal drainage
B) Complaint of nasal pain
C) Bilateral nose swelling and bruising
D) Inability to breathe through the nose

Question 18

Which patient in the ear,nose,and throat (ENT)clinic should the nurse assess first?

A) A 23-year-old who is complaining of a sore throat and has a muffled voice
B) A 34-year-old who has a "scratchy throat" and a positive rapid strep antigen test
C) A 55-year-old who is receiving radiation for throat cancer and has severe fatigue
D) A 72-year-old with a history of a total laryngectomy whose stoma is red and inflamed

Question 19

A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally.If the patient is unsuccessful in coughing up secretions,what action should the nurse take?

A) Encourage increased incentive spirometer use.
B) Encourage the patient to increase oral fluid intake.
C) Put on sterile gloves and use a sterile catheter to suction.
D) Preoxygenate the patient for 3 minutes before suctioning.

Question 20

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube.Which action by the nurse would best determine if the cuff has been properly inflated?

A) Use a manometer to ensure cuff pressure is at an appropriate level.
B) Check the amount of cuff pressure ordered by the health care provider.
C) Suction the patient first with a fenestrated inner cannula to clear secretions.
D) Insert the decannulation plug before the nonfenestrated inner cannula is removed.

Question 21

The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans.Which action is appropriate for the nurse to include in the plan of care?

A) Avoid giving patient warm liquids to drink.
B) Assess patient for allergies to penicillin antibiotics.
C) Teach the patient about the need to sleep in a warm, dry environment.
D) Teach patient to "swish and swallow" prescribed oral nystatin (Mycostatin).

Question 22

The clinic nurse is teaching a patient with acute sinusitis.Which interventions should the nurse plan to include in the teaching session (select all that apply)?

A) Decongestants can be used to relieve swelling.
B) Blowing the nose should be avoided to decrease the nosebleed risk.
C) Taking a hot shower will increase sinus drainage and decrease pain.
D) Saline nasal spray can be made at home and used to wash out secretions.
E) You will be more comfortable if you keep your head in an upright position.

Question 23

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September.Which patients should receive the inactivated influenza vaccination (select all that apply)?

A) A 76-year-old nursing home resident
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 cephalosporins

Question 24

When assessing a patient with a sore throat,the nurse notes anterior cervical lymph node swelling,a temperature of 101.6° F (38.7° C),and yellow patches on the tonsils.Which action will the nurse anticipate taking?

A) Teach the patient about the use of expectorants.
B) Use a swab to obtain a sample for a rapid strep antigen test.
C) Discuss the need to rinse the mouth out after using any inhalers.
D) Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs).

Question 25

The nurse assumes care of a patient who 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 a space between each answer choice [A,B,C,D].)

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