Deck 29: Nursing Management Upper Respiratory Problems

Question 1

The nurse is caring for a client with a tracheostomy tube and is inflating the cuff to the appropriate level. Which of the following actions is best for the nurse to implement?

A)Check the pilot balloon after inflation to ensure that it is firm.
B)Use a manometer to ensure cuff pressure is at an appropriate level.
C)Check the amount of cuff pressure ordered by the health care provider.
D)Fill the balloon until minimal air leakage around the cuff is auscultated.

Answer 1

Use a manometer to ensure cuff pressure is at an appropriate level.

Question 2

Which of the following clients in the respiratory disease clinic should the nurse assess first?

A)A 23-year-old, complaining of a sore throat, who has stridor
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

Answer 2

A 23-year-old, complaining of a sore throat, who has stridor

Question 3

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

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

Answer 3

The client asks how to clean the tracheostomy stoma and tube.

Question 4

The nurse is caring for a hospitalized older adult client who has posterior 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 client's temperature is 37.8°C (100°F).
D)The client complains of level 7 (0-10 scale) pain.

Question 5

Which of the following actions should the nurse take first when a client develops a nosebleed?

A)Pack both nares tightly with 1 cm ribbon gauze.
B)Pinch the lower portion of the nose for 10 minutes.
C)Prepare supplies that will be needed for cauterization.
D)Apply ice compresses over the client's nose and cheeks.

Question 6

An RN is observing a nursing student who is suctioning a hospitalized client with a tracheostomy in place. Which of the following actions by the student requires the RN to intervene?

A)The student preoxygenates the client for 1 minute before suctioning.
B)The student puts on clean gloves and uses a sterile catheter to suction.
C)The student inserts the catheter about 15 cm into the tracheostomy tube.
D)The student applies suction for 10 seconds while withdrawing the catheter.

Question 7

The nurse is caring for a client who is scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx. The client asks the nurse, "How will I talk after the surgery?" Which of the following responses by the nurse is best?

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 8

The nurse is obtaining a health history from a client with a 40 year, pack a day smoking history, symptoms of hoarseness and tightness in the throat, and difficulty swallowing. Which of the following questions 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 9

The nurse is deflating the cuff of a tracheostomy tube to evaluate the client's ability to swallow. Which of the following actions should the nurse implement?

A)Clean the inner cannula of the tracheostomy tube before deflation.
B)Deflate the cuff during the inhalation phase of the respiratory cycle.
C)Suction the client's mouth and trachea before deflation of the cuff.
D)Insert exactly the same volume of air into the cuff during reinflation.

Question 10

The nurse is caring for a client who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery, which of the following actions is priority?

A)Monitor for bleeding.
B)Assess breath sounds.
C)Clean the inner cannula every 8 hours.
D)Avoid changing the tracheostomy ties.

Question 11

The nurse is teaching a client with allergic rhinitis about management of the condition. Which of the following information should the nurse include in the teaching plan?

A)Over-the-counter (OTC) antihistamines cause sedation, so prescription antihistamines are usually ordered.
B)Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.
C)Use of oral antihistamines for a few weeks before the allergy season may prevent reactions.
D)Identification and avoidance of environmental triggers are the best ways to avoid symptoms.

Question 12

The nurse is providing discharge instructions for a client with a total laryngectomy. Which of the following client statements indicate that additional instruction is required?

A)"I must keep the stoma covered with a loose sterile 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 13

The nurse obtains the following assessment data for a client who has influenza. Which of the following information is most important to communicate to the health care provider?

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

Question 14

The nurse is caring for a client with an uncuffed tracheostomy tube who coughs violently during suctioning and dislodges the tracheostomy tube. Which of the following actions should the nurse take first?

A)Insert the obturator and attempt to reinsert the tracheostomy tube.
B)Position the client in an upright position with the neck extended.
C)Assess the client's oxygen saturation and notify the health care provider.
D)Ventilate the client with a manual bag until the health care provider arrives.

Question 15

Which of the following nursing actions should the nurse perform when suctioning a tracheostomy?

A)Insert tube 13-15 cm while suctioning.
B)Withdraw catheter in a straight time while applying intermittent suction.
C)Limit suction time to 10 seconds.
D)Oxygenate the client once all suctioning is completed.

Question 16

The nurse is teaching a client with laryngeal cancer about radiation therapy. Which of the following client statements indicate that the teaching has been effective?

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 17

The nurse is caring for a client with a tracheostomy who has a new prescription for a fenestrated tracheostomy tube. Which of the following actions should be included in the plan of care?

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 18

Which of the following causes is the most common cause of acute pharyngitis?

A)Fungal
B)Viral
C)Acute follicular
D)Peritonsillar

Question 19

The nurse is providing teaching to a client who has acute viral rhinitis about management of upper respiratory infections (URI). Which of the following client statements indicate that additional teaching is needed?

A)"I can take acetaminophen to treat discomfort."
B)"I will drink lots of juices and other fluids to stay 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 20

The nurse is caring for a client who has had an anterior packing for severe epistaxis. Which of the following nursing interventions should be included in the plan of care?

A)Educate the client to return in 3 days to have the nasal packing removed.
B)Reassure the client that the nose will look normal when the swelling subsides.
C)Instruct the client to keep the head elevated for 48 hours to minimize pain.
D)Teach the client to use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control.

Question 21

The nurse is reviewing the charts for five clients who are scheduled for their yearly physical examinations in October. Which of the following clients are considered a target population for the influenza vaccination? (Select all that apply.)

A)A 72-year-old client who has diabetes
B)A 36-year-old female client who is pregnant
C)A 42-year-old client who has a 15 pack-year smoking history
D)A 30-year-old client who takes corticosteroids for rheumatoid arthritis
E)A 9-month-old client who is teething

Question 22

The nurse is preparing a teaching plan for a client with acute sinusitis. Which of the following interventions should be included in the plan? (Select all that apply.)

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

Question 23

The nurse enters the room of a client 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?

A)The nasogastric (NG) tube is disconnected from suction and clamped off.
B)The client 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 client is coughing blood-tinged secretions from the tracheostomy.