Chapter 14: Care of Patients with Disorders of the Upper Respiratory System My Nursing Test Banks

Chapter 14: Care of Patients with Disorders of the Upper Respiratory System

MULTIPLE CHOICE

1. The nurse reminds the patient that a cold is contagious for about _____ days.

a.

2

b.

3

c.

4

d.

7

ANS: B

The contagion period of a viral cold is about 3 days.

DIF: Cognitive Level: Knowledge REF: 279 OBJ: 1 (theory)

TOP: Contagion of Colds KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

2. The nurse clarifies that the antibiotic given to the patient with a cold is to:

a.

cure the cold.

b.

reduce the symptoms.

c.

prevent a secondary bacterial infection.

d.

protect the immune system.

ANS: C

Antibiotics are given to people with a viral cold to prevent a secondary bacterial infection. There is no cure for a cold. Antibiotics will not reduce symptoms of a cold because a cold is viral in etiology, and antibiotics will not affect the immune system response to viral infections.

DIF: Cognitive Level: Application REF: 279 OBJ: 1 (theory)

TOP: Antibiotics KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

3. When the patient with an upper respiratory infection states that it is difficult to chew due to pain in the upper teeth, the nurse suspects:

a.

abscess.

b.

caries.

c.

sinusitis.

d.

pharyngitis.

ANS: C

While an abscess or dental caries can cause tooth pain, generalized pain in the upper teeth associated with an upper respiratory infection indicates sinusitis.

DIF: Cognitive Level: Comprehension REF: 279 OBJ: 1 (theory)

TOP: Sinusitis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

4. The 20-year-old who has laser surgery to remove the tonsils should be positioned postoperatively in the position of:

a.

side-lying.

b.

semi-Fowlers.

c.

prone.

d.

supine.

ANS: B

Semi-Fowlers position is the best position for the adult tonsillectomy patient to ensure adequate ventilation due to the airway being swollen and bleeding associated with the surgery. Side-lying, prone, and supine would not assist in ventilation.

DIF: Cognitive Level: Application REF: 281 OBJ: 2 (theory)

TOP: Positioning After Tonsillectomy KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

5. The patient with sleep apnea complains to the nurse that he is constantly fatigued. The nurse is most accurate in telling the patient that his fatigue is related to which factor?

a.

Oxygen deficiency

b.

Waking frequently during the night

c.

Increased respiratory effort

d.

Snoring

ANS: B

The periods of apnea and abrupt intake of air wakens the patient frequently during the night and reduces the amount of rapid eye movement (REM) sleep. Oxygen deficiency also occurs, but is related to other symptoms of sleep apnea. Increased respiratory effort is not usually associated with sleep apnea.

DIF: Cognitive Level: Application REF: 282 OBJ: 1 (theory)

TOP: Sleep Apnea KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. The nurse is caring for a patient during the immediate postoperative period following a rhinoplasty. The nurse is most concerned with which assessment finding?

a.

The patient complains of being cold and chilled.

b.

The patient complains of nausea.

c.

The nurse notices the patient swallowing frequently.

d.

The patient has a decreased fluid intake.

ANS: C

Frequent swallowing indicates bleeding that is trickling down the back of the throat. Feeling cold and chilly is a common symptom with surgery and is related to anesthetic and the cool surgical environment. Nausea may be experienced by some patients due to anesthetic. Fluid intake is not a symptom.

DIF: Cognitive Level: Application REF: 283 OBJ: 2 (theory)

TOP: Postoperative Care: Rhinoplasty KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

7. The patient has a tracheostomy with a one-way valve box that allows the patient to:

a.

drink.

b.

eat.

c.

cough.

d.

speak.

ANS: D

The one-way valve directs air through the larynx and allows the patient to talk.

DIF: Cognitive Level: Comprehension REF: 285-286 OBJ: 5 (theory)

TOP: One-Way Valve Box KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

8. To help reduce the anxiety of a new tracheostomy patient, the nurse should:

a.

be efficient in giving care quickly.

b.

give care with minimal conversation.

c.

delay teaching until tracheostomy is healed.

d.

offer reassurance of awareness of apprehension.

ANS: D

Offering reassurance to a patient who cannot speak is essential. Care should be unhurried with teaching and conversation. Giving care quickly or with minimal conversation may cause further anxiety. Teaching cannot be delayed until the tracheostomy is healed.

DIF: Cognitive Level: Application REF: 286 OBJ: 5 (theory)

TOP: Care of a Tracheostomy Patient KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity

9. The nurse is developing the care plan for a laryngectomy patient. Which patient need will be of the highest priority for the nurse to address?

a.

A method of pain control

b.

Family support

c.

A method of communication

d.

The need for long-term care

ANS: C

Pain control and family support are important, but the need of a method of communication is paramount for a new tracheostomy patient to allay anxiety, ensure accurate communication between the patient and the nurse, and make the patient comfortable that nursing staff are attentive. The need for long-term care may not be necessary.

DIF: Cognitive Level: Application REF: 287-288 | Nursing Care Plan 14-1

OBJ: 4 (theory) TOP: Laryngectomy: Need for Communication

KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity

10. The nurse instructs the laryngectomized patient that, in order to warm the inspired air during cold weather, the patient should:

a.

place hand over stoma.

b.

use scarf to cover stoma.

c.

wear moist dressing over stoma.

d.

stay in area of humidified air.

ANS: B

The fold of the scarf retains body heat and can warm air as the air passes through the scarf.

DIF: Cognitive Level: Comprehension REF: 289 OBJ: 4 (theory)

TOP: Warming Inspired Air KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

11. The nurse determines that the patient understands patient teaching regarding esophageal speech when witnessing the patient perform which activity?

a.

Inhaling air through the nose and forcing it down the esophagus

b.

Relaxing the diaphragm to allow air into the trachea and esophagus

c.

Coughing to express air

d.

Swallowing air and forcing it back up through the esophagus

ANS: D

Swallowing air and forcing it through the esophagus and moving the lips and tongue can produce speech. Inhaling air through the nose, relaxing the diaphragm, and coughing to express air are not methods to achieve esophageal speech.

DIF: Cognitive Level: Application REF: 289 OBJ: 4 (theory)

TOP: Esophageal Speech KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. The nurse is careful to apply suction prior to deflating the cuff on a cuffed tracheostomy in order to prevent:

a.

bleeding.

b.

excessive negative pressure.

c.

accidental dislodgement of the tube.

d.

aspiration.

ANS: D

By suctioning prior to deflating the cuff, the oral liquids that are trapped above the balloon cannot be aspirated. Bleeding, negative pressure, and dislodgement of the tube are not related to cuff inflation.

DIF: Cognitive Level: Application REF: Skill 14-1 (on Evolve)

OBJ: 5 (theory) TOP: Cuffed Tracheostomy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

13. When doing routine cleaning of a double-lumen tracheostomy tube, the nurse will include which of the following actions?

a.

Place the patient flat on the bed.

b.

Reinsert the inner cannula without touching the faceplate of the tracheostomy tube.

c.

Rinse the inner cannula in a basin of hydrogen peroxide.

d.

Clean the inner cannula with a pipe cleaner.

ANS: D

The inner cannula is cleaned with a pipe cleaner, the patient is put in the semi-Fowlers position, and the inner cannula is rinsed in sterile saline or sterile water, rather than peroxide.

DIF: Cognitive Level: Application REF: Skill 14-2 (on Evolve)

OBJ: 1 (clinical) TOP: Double-Lumen Tracheostomy Tube

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

14. The nurse is caring for a patient experiencing epistaxis. What should the nursess initial intervention be to stop the epistaxis?

a.

Have the patient lie back and hold ice to the nose.

b.

Firmly pack the nostrils with gauze.

c.

Press firmly on the area beneath the nose and lips.

d.

Have the patient sit forward and pinch the soft part of the nose.

ANS: D

Initial intervention is to pinch the soft part of the nose while the patient is sitting forward.

DIF: Cognitive Level: Comprehension REF: 280 OBJ: 2 (clinical)

TOP: Epistaxis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

15. The nurse is aware that the patient seeking antibiotic treatment for pharyngitis will only receive the desired medication if the condition is caused by:

a.

protozoa.

b.

bacteria.

c.

a virus.

d.

a previous infection.

ANS: B

Pharyngitis (sore throat) will be treated with an antibiotic only if the infection is deemed bacterial in etiology. Protozoa and viruses do not respond to antibiotics. A previous infection would not be enough cause for the primary care provider to prescribe an antibiotic.

DIF: Cognitive Level: Comprehension REF: 280-281 OBJ: 1 (theory)

TOP: Pharyngitis KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

16. The nurse is assisting the physician with insertion of a new tracheostomy tube. The physician asks for the obturator. The nurse correctly hands the physician which device?

a.

The guide for the tracheostomy tube to be inserted

b.

The scalpel used to make the tracheotomy stoma

c.

A single-cannula tracheostomy tube

d.

A cuffed tracheostomy tube

ANS: A

The obturator is used during insertion of a tracheostomy tube as a guide to protect against scraping the sides of the trachea with the sharp edge of the tube.

DIF: Cognitive Level: Comprehension REF: 285 OBJ: 5 (theory)

TOP: Types of Tracheostomy Tubes KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

MULTIPLE RESPONSE

17. The nurse advises that, to reduce the risk of giving a cold to another, one should: (Select all that apply.)

a.

cover the mouth and nose when sneezing.

b.

wash the hands frequently.

c.

use saline nose sprays.

d.

turn the head to the crook of the arm when coughing.

e.

drink juices with vitamin C.

ANS: A, B, D

Covering the mouth and nose when sneezing and coughing as well as frequent washing of hands will reduce the risk of passing a cold to another. Using saline sprays and drinking juices with vitamin C are not helpful in containing a cold.

DIF: Cognitive Level: Comprehension REF: 279 OBJ: 1 (theory)

TOP: Cold Contagion KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

18. Common causative organisms for the infection causing sinusitis are: (Select all that apply.)

a.

pneumococci.

b.

Pseudomonas.

c.

staphylococci.

d.

Haemophilus influenzae.

e.

streptococci.

ANS: A, D, E

The common organisms causing sinusitis are pneumococci, Haemophilus influenzae, and streptococci.

DIF: Cognitive Level: Comprehension REF: 279 OBJ: 1 (theory)

TOP: Causes of Sinusitis KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

19. The nurse instructs the adult post-tonsillectomy patient to avoid: (Select all that apply.)

a.

citrus fluids.

b.

hot fluids.

c.

milk products.

d.

coughing and sneezing.

e.

using a straw.

ANS: A, B, D, E

Milk products are acceptable for post-tonsillectomy patients. Citrus fluids should be avoided until the throat has healed. Hot fluids, coughing and sneezing, and using a straw may cause bleeding.

DIF: Cognitive Level: Application REF: 281 OBJ: 2 (theory)

TOP: Post-tonsillectomy Instruction KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

20. The nurse assesses the older adult with a family tendency of developing laryngeal cancer for: (Select all that apply.)

a.

history of smoking.

b.

alcohol abuse.

c.

exposure to asbestos.

d.

eating spicy foods.

e.

infection with Streptococcus bacteria.

ANS: A, B, C, D

Streptococcus bacteria are not considered a risk factor for laryngeal cancer; rather, infection with human papillomavirus is considered a risk factor. All other options are risk factors for laryngeal cancer.

DIF: Cognitive Level: Application REF: 283 OBJ: 1 (theory)

TOP: Risk Factors for Laryngeal Cancer KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

21. The nurse includes in the discharge instruction to a patient who has had a microlaryngoscopy with laser removal of polyps to: (Select all that apply.)

a.

be alert for massive swelling.

b.

return to work in 3 days.

c.

cough to expectorate blood.

d.

observe 2 days of voice rest.

e.

take opioids for pain.

ANS: B, D

Observation of voice rest for 2 days and return to work in 3 days are the basic instructions. There is minimal swelling or bleeding, and NSAIDs (not opioids) are used for pain control.

DIF: Cognitive Level: Application REF: 283-284 OBJ: 4 (theory)

TOP: Postoperative Care: Microlaryngoscopy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

22. The nurse setting up the environment for tracheal suction on a newly postoperative tracheostomy patient will: (Select all that apply.)

a.

auscultate lungs for retained secretions.

b.

wash hands and open sterile suction kit.

c.

don clean gloves and lift out catheter and connect to suction.

d.

don sterile gloves and prepare solutions from kit.

e.

perform suction with sterile supplies.

ANS: A, B, D, E

Sterile rather than clean gloves should be worn during the suctioning procedure. All other options are significant to perform suctioning safely and aseptically.

DIF: Cognitive Level: Analysis REF: Skill 14-1 (on Evolve)

OBJ: 2 (clinical) TOP: Tracheal Suction

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

23. The radical neck resection removes a large amount of tissue on the same side as the lesion. The tissues removed include: (Select all that apply.)

a.

all muscle, lymph nodes, and soft tissue from the lower edge of the mandible to the top of the clavicle.

b.

all muscle, lymph nodes, and soft tissue from the top of the trapezius to the midline.

c.

all muscle, lymph nodes, and soft tissue from the lower edge of the eye socket to the bottom of the maxilla, including the zygomatic arch.

d.

part of the tongue and parotid salivary glands.

e.

lower lip to midline.

ANS: A, B, C

The radical neck resection does not ordinarily include the tongue, parotid salivary glands, or lip.

DIF: Cognitive Level: Application REF: 283-284 OBJ: 2 (theory)

TOP: Radical Neck Resection KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

24. When epistaxis has been controlled, the nurse instructs the patient to: (Select all that apply.)

a.

avoid sneezing.

b.

rest for several hours until all threat of epistaxis is gone.

c.

avoid rubbing the nose.

d.

gently remove clotted blood from the occluded nostril.

e.

blow the nose gently in small breaths.

ANS: A, B, C

The patient should not blow the nose or attempt to remove clotted blood.

DIF: Cognitive Level: Application REF: 280 OBJ: 2 (clinical)

TOP: Epistaxis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

25. The clinic nurse is giving discharge instructions to the mother of a 12-year-old boy who has been diagnosed with a mild cold. Which statements by the mother demonstrate knowledge of care? (Select all that apply.)

a.

He will be receiving an antibiotic, correct?

b.

I will be sure he drinks plenty of apple and orange juice.

c.

If he runs a fever, I will give him 2 aspirin every 4 hours until his fever comes down.

d.

I will be sure he washes his hands well so he doesnt pass this on to his younger sister.

e.

Since his cold just started, zinc lozenges are a good idea for him to take.

ANS: B, D, E

Citrus juices and zinc lozenges are helpful in limiting the duration and severity of a cold. Hand hygiene helps prevent the spread of the virus. Antibiotics are not used for colds (because colds are viral in etiology) unless a secondary infection is present or there is an increased risk for a secondary infection. Aspirin should not be given to children under age 12 due an increased risk for Reyes syndrome.

DIF: Cognitive Level: Application REF: 277 | 279 OBJ: 1 (theory)

TOP: Treatment and Nursing Management: Colds

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

COMPLETION

26. The nurse encourages a patient with cancer of the larynx that the near-total laryngectomy is a new procedure that preserves the ability to __________ and to __________.

ANS:

speak; swallow

swallow; speak

The new technique does not rob the patient of the ability to speak or swallow, which makes rehabilitation easier.

DIF: Cognitive Level: Comprehension REF: 283-284 OBJ: 2 (theory)

TOP: Near-total Laryngectomy KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity

MATCHING

Place the steps of abdominal thrusts in proper sequence.

a.

Wrap hand around fist.

b.

Squeeze and thrust 5 times.

c.

Make a fist.

d.

Check status of breathing.

e.

Position fist, thumb foremost, over umbilicus.

27. Step 1

28. Step 2

29. Step 3

30. Step 4

31. Step 5

27. ANS: D DIF: Cognitive Level: Application REF: 282

OBJ: 3 (theory) TOP: Abdominal Thrusts

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

28. ANS: C DIF: Cognitive Level: Application REF: 282

OBJ: 3 (theory) TOP: Abdominal Thrusts

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

29. ANS: E DIF: Cognitive Level: Application REF: 282

OBJ: 3 (theory) TOP: Abdominal Thrusts

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

30. ANS: A DIF: Cognitive Level: Application REF: 282

OBJ: 3 (theory) TOP: Abdominal Thrusts

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

31. ANS: B DIF: Cognitive Level: Application REF: 282

OBJ: 3 (theory) TOP: Abdominal Thrusts

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

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