Question 1

A nurse assesses a client who reports waking up feeling very tired,even after 8 hours of good sleep.Which action should the nurse take first?

Accepted Answer

Clients are usually unaware that they have sleep apnea,but it should be suspected in people who have persistent daytime sleepiness and report waking up tired.Causes of the problem should be assessed before the client is offered suggestions for treatment.

Question 2

A nurse teaches a client who has open vocal cord paralysis.Which technique should the nurse teach the client to prevent aspiration?

Accepted Answer

The client with open vocal cord paralysis may aspirate.The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration.Tilting the head back would increase the chance of aspiration.Breathing slowly would not decrease the risk of aspiration,but holding the breath would.Keeping the head still and straight would not decrease the risk for aspiration.

Question 3

A nurse assesses a client who has a nasal fracture.The client reports constant nasal drainage,a headache,and difficulty with vision.Which action should the nurse take next?

Accepted Answer

The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebrospinal fluid (CSF).CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper.The other actions would be appropriate but are not as high a priority as assessing for CSF.A CSF leak would increase the client's risk for infection.

Question 4

A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil).The client asks,"How will this medication help me?" How should the nurse respond?

Accepted Answer

Modafinil is helpful for clients who have narcolepsy (uncontrollable daytime sleep)related to sleep apnea.This medication promotes daytime wakefulness.

Question 5

A nurse teaches a client to use a room humidifier after a laryngectomy.Which statement should the nurse include in this client's teaching?

Accepted Answer

Priority teaching related to the use of a room humidifier focuses on infection control.Clients should be taught to meticulously clean the humidifier to prevent the spread of mold or other sources of infection.Peppermint oil should not be added to a humidifier.The humidifier should be refilled with water as needed and should be used while awake and asleep.

Question 6

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place.Which actions should the nurse take? (Select all that apply.)

Accepted Answer

The nurse should observe for clear drainage because of the risk for cerebrospinal fluid leakage.The nurse should assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding.The nurse should also note whether the client is swallowing frequently because this could indicate postnasal bleeding.A nasal steroid would increase the risk for infection.It is too soon to change the packing,which should be changed by the surgeon the first time.

Question 7

A nurse is assessing clients on a rehabilitation unit.Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.)

Accepted Answer

Risk for asphyxiation related to inspissated oral and nasopharyngeal secretions is caused by poor oral hygiene.Clients at risk include those with altered mental status and level of consciousness (traumatic brain injury),dehydration,an inability to communicate (aphasic)and cough effectively (quadriplegic),and a risk of aspiration (aspiration precautions).The client with a fractured femur is at risk for a pulmonary embolism.

Question 8

While assessing a client who has facial trauma,the nurse auscultates stridor.The client is anxious and restless.Which action should the nurse take first?

Accepted Answer

Facial and neck tissue edema can occur in clients with facial trauma.Airway patency is the highest priority.Clients who experience stridor and hypoxia,manifested by anxiety and restlessness,should be immediately intubated to ensure airway patency.Albuterol decreases bronchi and bronchiole inflammation,not facial and neck edema.Although putting the client in high-Fowler's position and asking the client to perform breathing exercises may temporarily improve the client's comfort,these actions will not decrease the underlying problem or improve airway patency.

Question 9

A registered nurse (RN)cares for clients on a surgical unit.Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.)

Accepted Answer

The nurse can delegate stable clients to the LPN.The client who had a biopsy 2 days ago and the client who is awaiting gastric tube placement are stable.The client who is 6 hours post-surgery is not yet stable.The RN is the only one who can perform discharge and preoperative teaching; teaching cannot be delegated.

Question 10

A nurse cares for a client who has packing inserted for posterior nasal bleeding.Which action should the nurse take first?

Accepted Answer

The string should be attached to the client's cheek to hold the packing in place.The nurse needs to make sure that this does not move because it can occlude the client's airway.The other options are good interventions,but ensuring that the airway is patent is the priority objective.

Question 11

A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture.Which statements should the nurse include in this client's teaching? (Select all that apply.)

Accepted Answer

The client needs to know how to cut the wires in case of emergency.If the client vomits,he or she may aspirate.The client should also be taught to eat soft or liquid meals multiple times a day,irrigate the mouth with a Waterpik to prevent infection,and sleep in a semi-Fowler's position to assist in avoiding aspiration.Mouthwash with Benadryl is used for clients who have mouth pain after radiation treatment; it is not used to treat pain in a client with a mandibular fracture.

Question 12

A nurse cares for a client who had a partial laryngectomy 10 days ago.The client states that all food tastes bland.How should the nurse respond?

Accepted Answer

Many clients experience changes in taste after surgery.The nurse should identify foods that the client wants to eat to ensure the client maintains necessary nutrition.Although the nurse should collaborate with the speech therapist and dietitian to ensure appropriate replacement of protein,calories,and water,the other responses do not address the client's concerns.

Question 13

A nurse assesses clients on the medical-surgical unit.Which client is at greatest risk for development of obstructive sleep apnea?

Accepted Answer

The client at highest risk would be the one who is extremely overweight.None of the other clients have risk factors for sleep apnea.

Question 14

A nurse cares for a client who is experiencing epistaxis.Which action should the nurse take first?

Accepted Answer

The nurse should implement Standard Precautions and don gloves prior to completing the other actions.

Question 15

A nurse assesses a client who has facial trauma.Which assessment findings require immediate intervention? (Select all that apply.)

Accepted Answer

Stridor is a sign of airway obstruction and requires immediate intervention.Ecchymosis,or bruising,behind the ear is called "battle sign" and indicates basilar skull fracture.
Nasal stuffiness,edema of the cheek or chin,and eye pain do not interfere with respirations or neurologic function,and therefore are not priorities for immediate intervention.

Question 16

A nurse is assessing a client who has suffered a nasal fracture.Which assessment should the nurse perform first?

Accepted Answer

A patent airway is the priority.The nurse first should make sure that the airway is patent and then should determine whether the client is in pain and whether bone displacement or blood loss has occurred.

Question 17

A nurse cares for a client who is scheduled for a total laryngectomy.Which action should the nurse take prior to surgery?

Accepted Answer

The client will not be able to speak after surgery.The nurse should assist the client to choose a communication method that he or she would like to use after surgery.Assessing the client's airway and administering IV pain medication are done after the procedure.Although ambulation promotes health and decreases the complications of any surgery,this client's gait should not be impacted by a total laryngectomy and therefore is not a priority.

Question 18

After teaching a client who is prescribed "voice rest" therapy for vocal cord polyps,a nurse assesses the client's understanding.Which statement indicates the client needs further teaching?

Accepted Answer

Treatment for vocal cord polyps includes no speaking,no lifting,and no smoking.The client has to be educated not to even whisper when resting the voice.It is also appropriate for the client to stay out of rooms where people are smoking,to stay hydrated,and to use stool softeners.

Question 19

A nurse cares for a client after radiation therapy for lung cancer.The client reports a sore throat.Which action should the nurse take first?

Accepted Answer

Mouthwashes and throat sprays containing a local anesthetic agent such as lidocaine or diphenhydramine can provide relief from a sore throat after radiation therapy.Intravenous pain medications may be used if local anesthetics are unsuccessful.The nurse should explain to the client that this is normal and assess the client's neck,but these options do not decrease the client's discomfort.

Question 20

A nurse assesses a client who has developed epistaxis.Which conditions in the client's history should the nurse identify as potential contributors to this problem? (Select all that apply.)

Accepted Answer

Frequent causes of nosebleeds include trauma,hypertension,leukemia and other blood dyscrasias,inflammation,tumor,dry air,blowing or picking the nose,cocaine use,and intranasal procedures.Diabetes,migraines,and elevated platelets and cholesterol levels do not cause epistaxis.

Quiz 29: Care of Patients with Noninfectious Upper Respiratory Problems