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.

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 over-inflation. 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 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

Accepted Answer

The client's clinical manifestation of stridor suggests partial airway obstruction, a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other clients do not have diagnoses or symptoms that indicate any life-threatening problems.

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."

Accepted Answer

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

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.

Accepted Answer

Older clients 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

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.

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 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.

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 client 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 the range is 13-15 cm for most adult clients.

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."

Accepted Answer

Voice restoration 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 client 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 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?"

Accepted Answer

Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the client'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 client's symptoms are not suggestive of this diagnosis.
Streptococcal throat infections also may cause these clinical manifestations, but clients also will complain of pain and fever.

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.

Accepted Answer

The client'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 client 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 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.

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

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.

Accepted Answer

The most important intervention is to assist the client 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 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."

Accepted Answer

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

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

Accepted Answer

The crackles indicate that the client 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 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.

Accepted Answer

The first action should be to attempt to reinsert the tracheostomy tube to maintain the client's airway. Assessing the client'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 client may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. The client should be placed in a semi-Fowler's position if reinsertion of the tracheostomy tube is not successful.

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.

Accepted Answer

Suction time should not exceed 10 seconds. The tube is inserted 13-15 cm but not while suctioning. Suction is done intermittently while withdrawing the catheter but not in a straight line; the catheter should be rotated when withdrawing. Oxygenating the client after each tube insertion rather than when 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."

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 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.

Accepted Answer

Because the cuff is deflated when using a fenestrated tube, the client'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 client's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the client's vocal cords when using a 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

Accepted Answer

Viral pharyngitis accounts for approximately 70% of all cases of acute pharyngitis.

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."

Accepted Answer

The nurse should clarify that nasal decongestant sprays should be used for no more than 5 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.

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.

Accepted Answer

The client should be instructed to return in 48-72 hours to have the anterior packing removed. Maintaining the head in an elevated position is not required. NSAIDs increase the risk for bleeding and should not be used. Although return to a preinjury appearance is the goal, it is not always possible to achieve this result and the nurse should not provide false reassurance.

Quiz 29: Nursing Management Upper Respiratory Problems

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?

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

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?

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?

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

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?

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?

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?

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?

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?

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?

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?

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?

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?

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

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?

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?

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

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?

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?