Chapter 29: Nursing Management: Upper Respiratory Conditions:
Lewis’s Medical-Surgical Nursing, 5th Edition
1. The nurse is caring for a patient 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 patient in an upright position with the neck extended.
C. Assess the patient's oxygen saturation and notify the health care provider.
D. Ventilate the patient with a manual bag until the health care provider arrives.
Answer: A
Explanation: 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.
2. The nurse is preparing a teaching plan for a patient with acute sinusitis. Which of the
following interventions should be included in the plan? (Select all that apply.)
A. Taking a hot shower will increase sinus drainage and decrease pain.
B. Over-the-counter (OTC) decongestants can be used as required.
C. Saline nasal spray can be made at home and used to wash out secretions.
D. Blowing the nose forcefully should be avoided to decrease nosebleed risk.
E. You will be more comfortable if you keep your head in an upright position.
Answer: A, B, C, E
Explanation: The steam and heat from a shower will help thin secretions and improve
drainage. Antihistamines can be used. Patients can use either OTC sterile saline solutions or
home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture
decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using
the saline spray is recommended to expel secretions.
3. The nurse is caring for a patient 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 patient to return in 3 days to have the nasal packing removed.
B. Reassure the patient that the nose will look normal when the swelling subsides.
C. Instruct the patient to keep the head elevated for 48 hours to minimize pain.
D. Teach the patient to use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control.
,Answer: A
Explanation: The patient 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.
4. The nurse is teaching a patient 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.
Answer: D
Explanation: 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. Non-sedating antihistamines are available OTC.
5. The nurse is providing teaching to a patient who has acute viral rhinitis about
management of upper respiratory infections (URI). Which of the following patient
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."
Answer: C
Explanation: 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.
6. An RN is observing a nursing student who is suctioning a hospitalized patient with a
tracheostomy in place. Which of the following actions by the student requires the RN to
intervene?
A. The student preoxygenates the patient 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.
Answer: B
Explanation: 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 the range is 13–15 cm for most adult patients.
7. The nurse is deflating the cuff of a tracheostomy tube to evaluate the patient'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 patient's mouth and trachea before deflation of the cuff.
D. Insert exactly the same volume of air into the cuff during reinflation.
Answer: C
Explanation: 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.
8. Which of the following causes is the most common cause of acute pharyngitis?
A. Fungal
B. Viral
C. Acute follicular
D. Peritonsillar
Answer: B
Explanation: Viral pharyngitis accounts for approximately 70% of all cases of acute
pharyngitis.
9. The nurse is caring for a patient 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.
Answer: C
, Explanation: 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.
10. The nurse is caring for a patient 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.
Answer: B
Explanation: 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.
11. The nurse is teaching a patient with laryngeal cancer about radiation therapy.
Which of the following patient 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."
Answer: A
Explanation: 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.
12. The nurse is obtaining a health history from a patient 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?"
Lewis’s Medical-Surgical Nursing, 5th Edition
1. The nurse is caring for a patient 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 patient in an upright position with the neck extended.
C. Assess the patient's oxygen saturation and notify the health care provider.
D. Ventilate the patient with a manual bag until the health care provider arrives.
Answer: A
Explanation: 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.
2. The nurse is preparing a teaching plan for a patient with acute sinusitis. Which of the
following interventions should be included in the plan? (Select all that apply.)
A. Taking a hot shower will increase sinus drainage and decrease pain.
B. Over-the-counter (OTC) decongestants can be used as required.
C. Saline nasal spray can be made at home and used to wash out secretions.
D. Blowing the nose forcefully should be avoided to decrease nosebleed risk.
E. You will be more comfortable if you keep your head in an upright position.
Answer: A, B, C, E
Explanation: The steam and heat from a shower will help thin secretions and improve
drainage. Antihistamines can be used. Patients can use either OTC sterile saline solutions or
home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture
decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using
the saline spray is recommended to expel secretions.
3. The nurse is caring for a patient 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 patient to return in 3 days to have the nasal packing removed.
B. Reassure the patient that the nose will look normal when the swelling subsides.
C. Instruct the patient to keep the head elevated for 48 hours to minimize pain.
D. Teach the patient to use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control.
,Answer: A
Explanation: The patient 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.
4. The nurse is teaching a patient 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.
Answer: D
Explanation: 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. Non-sedating antihistamines are available OTC.
5. The nurse is providing teaching to a patient who has acute viral rhinitis about
management of upper respiratory infections (URI). Which of the following patient
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."
Answer: C
Explanation: 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.
6. An RN is observing a nursing student who is suctioning a hospitalized patient with a
tracheostomy in place. Which of the following actions by the student requires the RN to
intervene?
A. The student preoxygenates the patient 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.
Answer: B
Explanation: 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 the range is 13–15 cm for most adult patients.
7. The nurse is deflating the cuff of a tracheostomy tube to evaluate the patient'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 patient's mouth and trachea before deflation of the cuff.
D. Insert exactly the same volume of air into the cuff during reinflation.
Answer: C
Explanation: 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.
8. Which of the following causes is the most common cause of acute pharyngitis?
A. Fungal
B. Viral
C. Acute follicular
D. Peritonsillar
Answer: B
Explanation: Viral pharyngitis accounts for approximately 70% of all cases of acute
pharyngitis.
9. The nurse is caring for a patient 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.
Answer: C
, Explanation: 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.
10. The nurse is caring for a patient 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.
Answer: B
Explanation: 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.
11. The nurse is teaching a patient with laryngeal cancer about radiation therapy.
Which of the following patient 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."
Answer: A
Explanation: 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.
12. The nurse is obtaining a health history from a patient 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?"
