Question 1

Which of these patients in the respiratory disease clinic should the nurse assess first?

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

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?

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?

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?

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?

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

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

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?

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?

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

Accepted Answer

Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal capillaries. A firm pilot balloon indicates that the cuff is inflated but does not assess for overinflation. A health care provider's order is not required to determine safe cuff pressure. A minimal leak technique is an alternate means for cuff inflation, but this technique does allow a small air leak around the cuff and increases the risk for aspiration.

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?

Accepted Answer

Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.

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?

Accepted Answer

Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube.

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?

Accepted Answer

Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on irradiated skin, although they should not be used just before the radiation therapy.

Question 15

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "How will I talk after the surgery?" The best response by the nurse is,

Accepted Answer

Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.

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?

Accepted Answer

Suctioning of a stable patient can be delegated to LPN/LVNs. Assessments and patient teaching should be done by the RN.

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

Accepted Answer

The patient's mouth and trachea should be suctioned before the cuff is deflated to prevent aspiration of oral secretions. The amount of air needed to inflate the cuff varies and is adjusted by measuring cuff pressure or using the minimal leak technique, not by measuring the volume of air removed from the cuff. The cuff is deflated during patient exhalation so that secretions will be forced into the mouth rather than aspirated. There is no need to clean the inner cannula before cuff deflation.

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,

Accepted Answer

The stoma may be covered with clothing or a loose dressing, but this is not essential. The other patient comments are all accurate and indicate that the teaching has been effective.

Question 19

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

Accepted Answer

The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area somewhat, but will not be sufficient to stop bleeding. Cauterization or nasal packing may be needed if pressure to the nares does not stop bleeding, but these are not the first actions to take for nosebleed.

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?

Accepted Answer

Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients also will complain of pain and fever.

Quiz 27: Nursing Management: Upper Respiratory Problems