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Chapter 26: Upper Respiratory Problems Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement,

if made by the patient, indicates that the teaching was successful? “My nose will look normal after 24 to 48 hours.” “I can take 800 mg ibuprofen every 6 hours for pain.” “I will remove and reapply the nasal packing every day.” “I will elevate my head for 48 hours to minimize swelling.”

a. b. c. d.

ANS: D

Maintaining the head in an elevated position will decrease the amount of nasal swelling. Nonsteroidal antiinflammatory drugs, such as ibuprofen, increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not 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, especially in the first few weeks after surgery. DIF: Cognitive Level: Apply (application) REF: 476 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse plans to teach a patient how to manage allergic rhinitis. Which information should

the nurse include in the teaching plan? a. Using oral antihistamines for 2 weeks before the allergy season may prevent

reactions. b. Identifying and avoiding environmental triggers are the best way to prevent

symptoms. c. Frequent hand washing is the primary way to prevent spreading the condition to

others. d. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit

their use. ANS: B

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. Acute viral rhinitis (common cold) can be prevented by washing hands, but allergic rhinitis cannot. DIF: Cognitive Level: Apply (application) REF: 477 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 3. The nurse discusses management of upper respiratory infections (URIs) with a patient who

has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? a. “I will drink lots of juices and other fluids to stay well hydrated.” b. “I can use nasal decongestant spray until the congestion is gone.” c. “I can take acetaminophen (Tylenol) to treat my sinus discomfort.”

d. “I will watch for changes in nasal secretions or the sputum that I cough up.” ANS: B

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. DIF: Cognitive Level: Apply (application) REF: 480 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 4. The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube

in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a. Encourage increased incentive spirometer use. b. Encourage the patient to increase oral fluid intake. c. Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning. ANS: C

This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary; 30 seconds is recommended. Incentive spirometer use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner. DIF: Cognitive Level: Apply (application) REF: 488 TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 5. A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which

action should the nurse include in the plan of care in collaboration with the speech therapist? Leave the tracheostomy inner cannula inserted at all times. Place the decannulation cap in the tube before cuff deflation. Assess the ability to swallow before using the fenestrated tube. Inflate the tracheostomy cuff during use of the fenestrated tube.

a. b. c. d.

ANS: C

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. DIF: Cognitive Level: Apply (application) REF: 485 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 6. The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube.

Which action by the nurse would determine if the cuff has been properly inflated? Use a hand-held manometer to measure cuff pressure. Review the health record for the prescribed cuff pressure. Suction the patient through a fenestrated inner cannula to clear secretions. Insert the decannulation plug before removing the nonfenestrated inner cannula.

a. b. c. d.

ANS: A

Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patient’s airway is occluded. A health care provider’s order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings. DIF: Cognitive Level: Apply (application) REF: 487 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 7. Which statement by the patient indicates that teaching has been effective for a patient

scheduled for radiation therapy of the larynx? “I will need to buy a water bottle to carry with me.” “I should not use any lotions on my neck and throat.” “Until the radiation is complete, I may have diarrhea.” “Alcohol-based mouthwashes will help clean my mouth.”

a. b. c. d.

ANS: A

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 radiated skin, although they should not be used just before the radiation therapy. DIF: Cognitive Level: Apply (application) REF: 495 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 8. A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The

patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is 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?” ANS: A

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. Patients with streptococcal throat infections will also have pain and a fever. DIF: Cognitive Level: Apply (application) REF: 491 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 9. A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the

larynx asks the nurse, “Will I be able to talk normally after surgery?” What is the most accurate response by the nurse? 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 will have a permanent opening into your neck, and you will need

rehabilitation for some type of voice restoration.” d. “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.” ANS: C

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 lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible. DIF: Cognitive Level: Apply (application) REF: 493 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. 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 indicates that this identified problem is resolving? a. The patient allows the nurse to suction the tracheostomy. b. The patient’s spouse provides the daily tracheostomy care. c. The patient asks how to clean the tracheostomy stoma and tube. d. The patient uses a communication board to request “No Visitors.” ANS: C

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. DIF: Cognitive Level: Apply (application) REF: 495 TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity 11. The nurse completes discharge instructions for a patient with a total laryngectomy. Which

statement by the patient indicates that additional instruction is needed? “I must keep the stoma covered with an occlusive dressing.” “I need to have smoke and carbon monoxide detectors installed.” “I can participate in my prior fitness activities except swimming.” “I should wear a Medic-Alert bracelet to identify me as a neck breather.”

a. b. c. d.

ANS: A

The stoma may be covered with clothing or a loose dressing, but this is not essential. An occlusive dressing will completely block the patient’s airway. The other patient comments are all accurate and indicate that the teaching has been effective. DIF: Cognitive Level: Apply (application) REF: 495 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 12. Which action should the nurse take first when a patient develops epistaxis? a. Pack the affected nare tightly with an epistaxis balloon. b. Apply squeezing pressure to the nostrils for 10 minutes.

c. Obtain silver nitrate that may be needed for cauterization. d. Instill a vasoconstrictor medication into the affected nare. ANS: B

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 but will not be sufficient to stop bleeding. Cauterization, nasal packing, and vasoconstrictors are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed. DIF: Cognitive Level: Analyze (analysis) REF: 476 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 13. A 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? Monitor the incision for bleeding. Maintain adequate IV fluid intake. Keep the patient in semi-Fowler’s position. Teach the patient to suction the tracheostomy.

a. b. c. d.

ANS: C

The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler’s position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube. The patient may be taught to suction after the tracheostomy is stable, if needed, but not during the immediate postoperative period. DIF: Cognitive Level: Analyze (analysis) REF: 488 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 14. After a laryngectomy, a patient coughs violently during suctioning and dislodges the

tracheostomy tube. Which action should the nurse take first? Arrange for arterial blood gases to be drawn immediately. Cover stoma with sterile gauze and ventilate through stoma. Attempt to reinsert the tracheostomy tube with the obturator in place. Assess the patient’s oxygen saturation and notify the health care provider.

a. b. c. d.

ANS: C

The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient’s airway. 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. Assessing the patient’s oxygenation is an important action, but it is not as appropriate until there is an established airway. DIF: Cognitive Level: Analyze (analysis) REF: 488 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first? a. A patient who is complaining of a sore throat and has a muffled voice b. A patient who has a “scratchy throat” and a positive rapid strep antigen test c. A patient who is receiving radiation for throat cancer and has severe fatigue d. A patient with a history of a total laryngectomy whose stoma is red and inflamed ANS: A

The patient’s clinical manifestation of a muffled 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. DIF: Cognitive Level: Analyze (analysis) REF: 484 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse obtains the following assessment data on an older patient who has influenza. Which

information will be most important for the nurse to communicate to the health care provider? Fever of 100.4° F (38° C) Diffuse crackles in the lungs Sore throat and frequent cough Myalgia and persistent headache

a. b. c. d.

ANS: B

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 manifestations of influenza and are treated with supportive care measures such as over-the-counter pain relievers and increased fluid intake. DIF: Cognitive Level: Analyze (analysis) REF: 481 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 17. Which nursing action could the registered nurse (RN) working in a skilled care hospital unit

delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? a. Assess the patient’s risk for aspiration. b. Suction the tracheostomy when directed. c. Teach the patient to provide tracheostomy self-care. d. Determine the need for tracheostomy tube replacement. ANS: B

Suctioning of a stable patient can be delegated to LPNs/LVNs. Patient assessment and patient teaching should be done by the RN. DIF: Cognitive Level: Apply (application) REF: 490 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

18. The nurse is caring for a hospitalized older patient who has nasal packing in place after a

nosebleed. Which assessment finding will require the most immediate action by the nurse? The oxygen saturation is 89%. The nose appears red and swollen. The patient reports level 8 (0 to 10 scale) pain. The patient’s temperature is 100.1° F (37.8° C).

a. b. c. d.

ANS: A

Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the low O2 saturation. DIF: Cognitive Level: Analyze (analysis) REF: 476 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 19. After being hit by a baseball, a patient arrives in the emergency department with a possible

nasal fracture. Which finding by the nurse is most important to report to the health care provider? a. Clear nasal drainage b. Complaint of nasal pain c. Bilateral nose swelling and bruising d. Inability to breathe through the nose ANS: A

Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate any complications. DIF: Cognitive Level: Analyze (analysis) REF: 476 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being

“stuck up my nose” and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first? a. Notify the clinic health care provider. b. Obtain aerobic culture specimens of the drainage. c. Ask the patient about how the cotton got into the nose. d. Have the patient occlude the left nare and blow the nose. ANS: D

Because the highest priority action is to remove the foreign object from the nare, the nurse’s first action should be to assist the patient to remove the object. The other actions are also appropriate but should be done after attempting to clear the nose. DIF: Cognitive Level: Analyze (analysis) REF: 482 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

21. The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans.

Which action is appropriate for the nurse to include in the plan of care? Assess patient for allergies to penicillin antibiotics. Teach the patient to sleep in a warm, dry environment. Avoid giving the patient warm food or warm liquids to drink. Teach patient to “swish and swallow” prescribed oral nystatin

a. b. c. d.

ANS: D

Oral or ph...