Test Bank NSG 210 Caring for Clients With Upper Respiratory Disorders Questions &Answers & Rationale,100% CORRECT

Test Bank NSG 210 Caring for Clients With Upper Respiratory Disorders Questions &Answers & Rationale 1. You are caring for a client who is post–sinus surgery. When you assess this client, you ask him how many fingers you are holding up. Why do you assess postoperative visual acuity? A) To assess possible hemorrhage B) To assess damage to the optic nerve C) To assess postoperative infection D) To assess impaired drainage Ans: B Feedback: A client who has undergone a sinus surgery faces a serious risk of damage to the optic nerve. Therefore, the nurse assesses postoperative visual acuity by asking the client to identify the number of fingers displayed. To assess possible hemorrhage, the nurse observes the client for repeated swallowing. The nurse assesses for pain over the involved sinuses and not a postoperative infection or an impaired drainage. 2. You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? A) Incrusted mucous membranes B) Hardened secretions C) Erosion of the trachea D) Noisy breathing Ans: D Feedback: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following a tracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea. 3. You are performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would you ask the client about the use of herbal supplements? A) They produce anorexia. B) They impair the immune system. C) They prolong bleeding. D) They lower high-density lipoprotein levels. Ans: C Feedback: The nurse must find out the bleeding tendencies of clients scheduled for tonsillectomy and adenoidectomy. Therefore, the nurse asks the clients about any recent use of herbal supplements. The nurse must ask about the use of these supplements because they may prolong bleeding. A client may experience anorexia because of a diminished sense of taste and smell following a laryngectomy. Similarly, excess zinc impairs the immune system and lowers the levels of high-density lipoproteins. These symptoms are not caused by herbal supplements. 4.A client comes into the emergency department with epistaxis. What intervention should you perform when caring for a client with epistaxis? A) Apply a moustache dressing. B) Provide a nasal splint. C) Apply direct continuous pressure. D) Place the client in a semi-Fowler's position. Ans: C Feedback: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction. 5. You are presenting about upper respiratory infections at an educational event for a local community group. What should you be sure to include regarding cold tablets containing antihistamines? A) They dilute the nasal secretions. B) They lead to frequent sinus drainage. C) They decrease discomfort temporarily. D) They prolong bleeding. Ans: C Feedback: Some cold tablets contain antihistamines that thicken the nasal secretions. Although this action may temporarily decrease the discomfort of profuse nasal secretions, thickened secretions can block the drainage openings of the sinus cavity, leading to the failure of the sinuses to drain adequately. Aspirin prolongs bleeding. 6. You are caring for a client who is status post nasal polypectomy. What would you instruct this client to report? A) Excessive swallowing B) Nasal stuffiness C) Diarrhea D) Coughing Ans: A Feedback: The nurse inspects the nasal packing and dressings frequently for bleeding and asks the client to report excessive swallowing, which can indicate bleeding. Options B, C, and D are incorrect. Nasal stuffiness and diarrhea do not indicate postoperative bleeding. Coughing can loosen or expel scabs on the surgical wounds. 7. You are an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would you be sure to include in your workshop? Select all that apply. A) Alcohol B) Age C) Tobacco D) Industrial pollutants E) Region of country you live in Ans: A, C, D Feedback: Carcinogens, such as tobacco, alcohol, and industrial pollutants, are associated with laryngeal cancer. 8. You are mentoring a new graduate nurse. Today, the two of you are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would you respond? Select all that apply. A) Absence of secretions B) Aspiration C) Infection D) Injury to the laryngeal nerve E) Penetration of the anterior tracheal wall Ans: B, C, D Feedback: The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall. 9. You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? A) Airway patency B) Level of consciousness C) Psychological status D) Pain level Ans: A Feedback: The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation. The priorities are always airway, breathing, and then circulation. 10. You are caring for a client who is 42 years old and status post adenoidectomy. You find the client in respiratory distress when you enter his room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect? A) Infection B) Postoperative bleeding C) Edema of the upper airway D) Plugged tracheostomy tube Ans: C Feedback: An endotracheal tube is inserted through the mouth or nose into the trachea to provide a patent airway for clients who cannot maintain an adequate airway on their own. The scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy tube. 11. The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections? A) Administer an over-the-counter decongestant. B) Use an anti-allergy medication to decrease rhinitis. C) Place a warm cloth over the sinus area of the forehead. D) Gently blow the nose to eliminate nasal secretions. Ans: A Feedback: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opens the nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best. 12. The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose? A) CBC with differential B) Transillumination of the sinus C) Nasal culture D) Magnetic resonance imaging (MRI) Ans: B Feedback: Transillumination and x-rays of the sinuses may show a change in the shape of or confirms that there is fluid in the sinus cavity. CBC with differential can note an elevated white blood cell count but not confirm fluid in the sinus cavity. A nasal culture can note bacteria in the nares. An MRI is an expensive procedure which is not typically prescribed for a potential infection and not specifically ordered to identify fluid in the sinus cavity. 13. The nurse is caring for a client diagnosed with coryza possibly from the rhinovirus. Vital signs are temperature: 101.2° F, pulse: 72 beats/minute, respirations: 28 breaths/minute, blood pressure: 112/70 mm Hg. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are course in the bases. Which afternoon assessment finding suggests the advancement to an infectious process? A) Achiness B) Headache C) Temperature rise D) Increased respiratory rate Ans: C Feedback: Coryza refers to the common cold many times associated with a virus such as the rhinovirus. The nurse notes that the client is currently febrile. A rise in the temperature is interpreted that the client continues to have a sustained elevated temperature which suggests a bacterial infection. All viruses can include symptoms of achiness, headache, and an increase in the respiratory rate. Increased respiratory rate does not always indicate infection because it can be a sign of a multitude of other problems. 14. The nurse is caring for a geriatric client brought to the emergency department after being found by her children feeling poorly with an elevated temperature. Laboratory tests confirm influenza type A, a respiratory virus. Which medical treatment would the nurse anticipate in the discharge instructions? Select all that apply. A) Rest B) Increased fluids C) Antibiotics D) Antiemetics E) Saline gargles F) Antitussives Ans: A, B, E, F Feedback: Influenza type A is the most common cause of the flu initiated by a respiratory virus. Common discharge instructions include rest, increased fluids to thin respiratory secretions, saline gargles to help prevent a throat infection such a strep throat, and antitussives if the client is coughing. Antibiotics are not used with a virus unless a bacterial infection subsequently develops. Antiemetics are used for nausea and vomiting not commonly associated with a common respiratory virus. 15. The nurse is caring for a client in a physician's office whose x-ray of the sinus reveals exudate in the maxillary sinus. Which equipment must the nurse have present in the room? A) Otoscope B) Ophthalmoscope C) Irrigation equipment D) Tuning fork Ans: C Feedback: Note the keyword as “must”. The nurse would have sinus irrigation equipment available for the physician as saline irrigation of the maxillary sinus is done to remove exudate and promote drainage. This is most helpful as a condition which could lead to an infection is documented. An otoscope and tuning fork may be present in the room for further assessment. An ophthalmoscope is typically not needed. 16.A nurse is caring for a client following nasal surgery. Which assessment finding best indicates current bleeding? A) Ruddy colored drainage on the nasal dressing B) Occasional nonproductive cough C) Frequent swallowing D) Pressure in the nasal cavity Ans: C Feedback: Standards of postoperative care include assessment for postoperative bleeding with symptoms such as repeated swallowing. Swallowing indicates a slow oozing or dripping down the back of the throat. Ruddy colored drainage indicates old drainage. Occasional nonproductive cough could possibly indicate a problem but is not as definitive as swallowing. Pressure in the nasal cavity is to be expected. 17. The nurse in the walk-in clinic obtains a history of an upper respiratory infection with a red, sore throat. The client has been febrile for 3 days. Which nursing assessment should be stressed? A) Lung fields B) Voiding C) Joint pain D) Mentation Ans: B Feedback: A pharyngitis occurs from inflammation of the throat, typically from a virus or bacteria. The most serious bacteria are the group A streptococci, commonly referred to as strep throat. Strep throat can have serious cardiac and renal complications, including sepsis. Assessing voiding can be an indication of renal status. Lung fields, joint pain, and mentation are completed in the head-to-toe assessment. 18. The nurse is providing suggestions to a client diagnosed with the effects of coryza. Which home remedy is appropriate when combined with medical treatment for pharyngitis? A) Cool mist humidifier B) Lavender scent C) Ice chips D) Salt water gargle Ans: D Feedback: A salt water or saline gargle combines moisture from the water with sodium from the salt to treat the infection and aid in associated discomfort. Humidification and ice chips are also acceptable but just aids in soothing moisture to the air aiding in discomfort. A lavender scent is relaxing. 19. The nurse is receiving the post-tonsillectomy and post-adenoidectomy client in the postanesthesia care unit (PACU). The nurse aide is assisting the client from the stretcher to the bed. The client remains drowsy from anesthesia. In which position would the nurse instruct the nurse aide to place the client? A) On a side B) Supine C) Semi-Fowler's D) High-Fowler's Ans: A Feedback: Upon receiving the client in the PACU, the client is drowsy and not fully conscious. A standard of care to prevent aspiration is to place the client lying on either side with an emesis basin to catch drainage. Laying the client is a supine position, semi-Fowler's position, or high-Fowler's position does not provide an easy exit for secretions as the client is recovering from the anesthesia. 20. The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, “Elevate the head of the bed 45°.” This assists in meeting which nursing goal? A) The client will have decreased pain. B) The client will remain alert and oriented. C) The client will have decreased edema. D) The client will have increased tissue perfusion. Ans: C Feedback: Elevating the head of the bed 45° when the client is fully awake decreases surgical edema and increases lung expansion. At this point in the recovery, elevating the head of the bed will not decrease the surgical pain as pain medication will be needed. Elevating the head of the bed will not affect mentation nor increase the blood supply. 21. The nurse is providing discharge instructions to a client diagnosed with postoperative tonsillectomy and adenoidectomy. Which discharge instructions would the nurse include? Select all that apply. A) Postoperative bleeding most frequently occurs in the hours after surgery. B) Avoid carbonated fluids. C) Gradually increase fluids then add soft foods. D) Apply an ice collar to the neck area. E) Gargle with warm saline water. F) Limit pain medications to the nighttime. Ans: B, C, D, E Feedback: A client may be at risk for postoperative bleeding for several days following the surgical procedure as the scab may be removed from the surgical site early causing the bleeding. Clients should avoid carbonated beverages and citrus fluids or foods because these agents are caustic to the suture line. The client should gradually increase fluids from thin liquids to thick liquids then soft foods through the recovery process. Applying an ice collar and gargling with saline decreases swelling and aids in preventing infection. Pain medication would be appropriate throughout the day, not just at night. 22. The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? A) “I have environmental allergies.” B) “I smoke a pack of cigarettes a day.” C) “I used my voice in excess over the weekend.” D) “I was chewing ice chips all day long.” Ans: D Feedback: Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes. 23. The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention? A) Epistaxis, twice last week B) Aphonia following a football game C) Hoarseness for 2 weeks D) Laryngitis following a cold Ans: C Feedback: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity. 24. The emergency department nurse is assessing a client following a motor vehicle accident. The nurse notes facial deformities with swelling and bleeding and a clear drainage coming from the nares. Which diagnostic test is completed to determine if the clear drainage is cerebrospinal fluid? A) A serum CBC B) A Nitrazine paper C) A Dextrostix D) A glucometer check Ans: C Feedback: When clear drainage is observed from the nares of a client, a Dextrostix is used to determine the presence of glucose which is present in cerebrospinal fluid. A serum CBC would provide information on red and white blood cell count. A low red blood cell count is may be found due to hemorrhage that has occurred. Nitrazine paper is under to assess vaginal secretions for the presence of amniotic fluid. A glucometer check will provide information on serum glucose, not the glucose level in the cerebrospinal fluid. 25. The nurse is caring for a client experiencing laryngeal trauma. Upon assessment, swelling and bruising is noted to the neck. Which breath sound is anticipated? A) Rhonchi in the bronchial region B) Audible stridor without using a stethoscope C) Crackles in the bases of the lungs D) Diminished breath sounds throughout Ans: B Feedback: The nurse anticipates hearing audible stridor without needing a stethoscope due to the neck swelling narrowing the airway. Rhonchi in the bronchial region is heard lower in the airways and crackles are heard in the bases of the lungs. Diminished breath sounds that occur throughout are indicative of airway obstruction and not indicative of laryngeal swelling. 26. The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply. A) A decreased respiratory rate B) Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 C) Nasal flaring with abdominal retractions D) Administration of a corticosteroid inhaler for quick relief E) Lung sounds of stridor F) Increased respiratory effort Ans: B, C, E, F Feedback: The nurse would be calling to report signs of respiratory distress. This includes nasal flaring with abdominal retractions, stridor and an increased respiratory effort. Also arterial blood gases with an elevated CO2 and lower oxygen level indicates respiratory compromise. An increased respiratory rate occurs in respiratory compromise. Administration of a corticosteroid decreases inflammation over a period of time. 27. The nurse is caring for the client who presents to the clinic with hoarseness for 2 months. Further testing diagnoses laryngeal cancer with the treatment plan of a radical neck dissection. When reinforcing information provided by the physician, which nursing instruction is most correct? A) Laser surgery is a possibility with limited side effects. B) The physician removes lymph nodes, muscles and tissue. C) Once the tissue is removed, no further treatment is necessary. D) You will be able to speak normally once the swelling subsides. Ans: B Feedback: When the physician prescribes a radical neck dissection, the disease has extended beyond the larynx. The physician removes lymph nodes, muscle, and tissue. Laser surgery is completed for early lesions and does not have the ability to remove all of the structure needed. Chemotherapy and radiation is typically administered. The client will lose the ability to speak normally. 28.A client recently diagnosed with laryngeal cancer and awaiting a laryngectomy was encouraged to attend a support group prior to surgery. The client asked the nurse about the name of the laryngeal speech method where the client speaks through the wall of the trachea with a device. The nurse is correct to provide teaching on which method? A) Esophageal speech B) An electric larynx C) A tracheoesophageal puncture D) An artificial voice box Ans: C Feedback: A tracheoesophageal puncture is the method where a client speaks through a surgical opening in the posterior wall of the trachea with the assistance of a device. Esophageal speech occurs from swallowing air and forming words with the lips. An electronic larynx is a throat vibrator. There is no electronic voice box on the market. 29.The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care? A) Develop an alternate method of communication. B) Encourage oral nutrition on the second postoperative day. C) Maintain the client in a low-Fowler's position. D) Assess the tracheostomy cuff for leaks. Ans: A Feedback: The client with a total laryngectomy is not able to speak. Communication needs to be established using an alternate method. The client typically has difficulty with swallowing due to edema in the immediate postoperative period. Alternate forms of nutrition are used. The tracheostomy cuff is often deflated for periods of time. The head of the bed is maintained in a semi-Fowler's position to decrease edema. 30.A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first? A) Call for the registered nurse to reinsert the tube. B) Place a dilator in the stoma to maintain the opening. C) Cover the tracheostomy site with a sterile gauze to prevent infection. D) Call for an ambulance and transfer the client to the emergency department. Ans: B Feedback: If the tracheostomy tube becomes dislodged, a dilator is initially placed to hold the edges of the stoma apart until a physician is able to reinsert the tube. A tracheal tube must never be forced back into place. Covering the tracheostomy site with gauze can obstruct the stoma, decreasing ventilation. If needed, an ambulance may be called to transport the client to the emergency department but not until the airway is stabilized. 31.A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy? A) “I must carry tissues with me.” B) “I must give up my love of pool aerobics.” C) “I will not be able to have the tracheostomy removed.” D) “Tell my wife about it, I do not want to touch it.” Ans: D Feedback: Not wanting to participate in care and diverting the care to others indicates that the client has not accepted the tracheostomy. It is correct to carry tissues with the client because new tracheostomy tubes produce much mucous due to the irritation of the tube in the throat. Consideration need to be arranged by being in a swimming pool may be completed as long as water does not surround the new tracheostomy. Stating the reality of not being able to remove the tracheostomy provides data that the client is accepting the tracheostomy as part of life. 32. The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised? A) Obtain vital signs. B) Monitor heart rhythm. C) Auscultate lung sounds. D) Assess capillary refill. Ans: C Feedback: Major goals of intubation are to improve respirations and maintain a patent airway for gas exchange. Regular auscultation of the lung fields is essential in confirming that air is reaching the lung fields for gas exchange. All other options are important to provide assessment data. 33. The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation? A) Copious mucous secretions B) Sudden restlessness C) Harsh cough D) Rhonchi in lung fields Ans: B Feedback: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube. A harsh cough and rhonchi in the lung fields is common with the presence of mucous secretions. 34.A client visits the physician's office concerned about possible sleep apnea. The client states he lives alone and fears that he will not awaken from sleep. The client states that he has many symptoms which may indicate sleep apnea. Which symptom, stated by the client, is not a symptom of sleep apnea? A) “I wake myself up by snoring several times each night.” B) “I wake up in the morning with a headache.” C) “I have trouble concentrating throughout the day.” D) “I have pressure in the middle of my chest at night.” Ans: D Feedback: Signs of pressure in the middle of the chest are not indicative of sleep apnea and require further instruction and investigation by the nurse. A cardiac or epigastric cause may be producing the symptoms. All of the other options are symptoms of sleep apnea. 35. The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room? A) A ventilator B) A face mask C) A rigid shell D) A nasal cannula Ans: B Feedback: A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device. 36. The nurse is caring for a client with a new tracheostomy. Which of the following nursing diagnoses are priorities? Select all that apply. A) Ineffective Airway Clearance related to increased secretions B) Risk for Infection related to operative incision and tracheostomy tube placement C) Knowledge Deficit related to care of the tracheostomy tube and surrounding site D) Impaired Gas Exchange related to shallow breathing and anxiousness Ans: A, D Feedback: The client with a new tracheostomy tube has increased secretions, which may become dried and occlude the airway or plug the airway requiring frequent suctioning. Impaired Gas Exchange is an equally important diagnosis. These are related to airway and breathing and are priorities. 37. The nurse is caring for a client with an upper respiratory disorder. The client states he have a hacky, nonproductive cough, which wakens him during the night. Which over-the- counter medication would the nurse suggest to diminish the cough during the night? A) Benadryl B) Robitussin C) Pseudoephedrine D) Flonase Ans: B Feedback: Robitussin acts on the central nervous system to raise the cough threshold and dampen the cough reflex. Benadryl is an antihistamine which relieves symptoms associated with allergies. Pseudoephedrine relieves nasal congestion associated with sinusitis, colds, and allergies. Flonase reduces tissue edema.