Question 1

The nurse enters the room of a patient who has just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? Put a comma and space between each solve choice (a, b, c, d, etc.) ____________________
A) The nasogastric ( NG ) tube is disconnected from suction and clamped off.
B) The patient is in a side-lying position with the head of the bed flat.
C) The Hemovac in the neck incision contains 200 mL of bloody drainage.
D) The patient is coughing blood-tinged secretions from the tracheostomy.

Accepted Answer

B, D, C, A
The patient should first be p...

Question 2

After a patient has undergone a rhinoplasty, which nursing intervention will be included in the plan of care?

Accepted Answer

A)   Educate the patient about how to safely remove and reapply nasal packing.
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 swelling and pain.
D)   Teach the patient to use nonsteroidal anti-inflammatory drugs (NSAIDs)  for pain control.E) B) and D)
F) All of the above

Question 3

When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow, it is important to

Accepted Answer

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.E) None of the above
F) C) and D)

Question 4

When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to

Accepted Answer

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.E) A) and D)
F) None of the above

Question 5

The nurse is reviewing the charts for five patients who are scheduled for their yearly physical examinations in October. Which of the following patients will require the inactivated influenza vaccination (select all that apply) ?

Accepted Answer

A)   A 56-year-old patient who is allergic to eggs
B)   A 36-year-old female patient who is pregnant
C)   A 42-year-old patient who has a 15 pack-year smoking history
D)   A 30-year-old patient who takes corticosteroids for rheumatoid arthritis
E)   A 24-year-old patient who has allergies to penicillin and the cephalosporinsF) A) and B)
G) A) and C)

Question 6

The teaching plan for a patient with acute sinusitis will need to include which of the following interventions (select all that apply) ?

Accepted Answer

A)   Taking a hot shower will increase sinus drainage and decrease pain.
B)   Over-the-counter ( OTC )  antihistamines can be used to relieve congestion and inflammation.
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.F)  None of aboveG) C) and E)
H) A) and C) A, B, C, E

Question 7

Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN/LVN who is caring for a patient with a permanent tracheostomy?

Accepted Answer

A)   Assessing the patient's risk for aspiration
B)   Suctioning the tracheostomy when needed
C)   Educating the patient about self-care of the tracheostomy
D)   Determining the need for replacement of the tracheostomy tubeE) C) and D)
F) All of the above

Question 8

Which action should the nurse take first when a patient develops a nosebleed?

Accepted Answer

A)   Pack both nares tightly with 1/2-inch 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 patient's nose and cheeks.E) A) and C)
F) None of the above

Question 9

After discussing management of upper respiratory infections (URI)  with a patient who has acute viral rhinitis, the nurse determines that additional teaching is needed when the patient says

Accepted Answer

A)   "I can take acetaminophen (Tylenol)  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."E) None of the above
F) C) and D)

Question 10

A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?

Accepted Answer

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.E) A) and D)
F) A) and B) A

Question 11

A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective?

Accepted Answer

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."E) C) and D)
F) B) and D)

Question 12

An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene?

Accepted Answer

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 5 inches into the tracheostomy tube.
D)   The student applies suction for 10 seconds while withdrawing the catheter.E) None of the above
F) C) and D) B

Question 13

The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to treat a nosebleed. Which of the following assessment findings will require the most immediate action by the nurse?

Accepted Answer

A)   The oxygen saturation is 89%.
B)   The nose appears red and swollen.
C)   The patient's temperature is 100.1° F ( 37.8° C ) .
D)   The patient complains of level 7 ( 0 to 10 scale )  pain.E) C) and D)
F) A) and D)

Question 14

The nurse obtains the following assessment data in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider?

Accepted Answer

A)   Fever of 100.4° F ( 38° C ) 
B)   Diffuse crackles in the lungs
C)   Sore throat and frequent cough
D)   Myalgia and persistent headacheE) A) and B)
F) B) and C)

Question 15

When the 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?

Accepted Answer

A)   Monitor for bleeding.
B)   Assess breath sounds.
C)   Clean the inner cannula every 8 hours.
D)   Avoid changing the tracheostomy ties.E) B) and D)
F) All of the above

Question 16

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "How will I talk after the surgery?" The best response by the nurse is,

Accepted Answer

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."E) B) and C)
F) A) and B)

Question 17

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 is the best indicator that the problem identified in this nursing diagnosis is resolving?

Accepted Answer

A)   The patient lets the spouse provide tracheostomy care.
B)   The patient allows the nurse to suction the tracheostomy.
C)   The patient asks how to clean the tracheostomy stoma and tube.
D)   The patient uses a communication board to request "No Visitors."E) A) and B)
F) A) and C)

Question 18

Which of these patients in the respiratory disease clinic should the nurse assess first?

Accepted Answer

A)   A 23-year-old, complaining of a sore throat, who has a "hot potato" voice
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 inflamedE) None of the above
F) All of the above

Question 19

When teaching the patient with allergic rhinitis about management of the condition, the nurse explains that

Accepted Answer

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 way to avoid symptoms.E) None of the above
F) B) and C)

Question 20

After completing discharge instructions for a patient with a total laryngectomy, the nurse determines that additional instruction is needed when the patient says,

Accepted Answer

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."E) A) and D)
F) None of the above

Exam 27: Nursing Management: Upper Respiratory Problems

Correct Answer
verified
B, D, C, A
The patient should first be p...
View Answer

After a patient has undergone a rhinoplasty, which nursing intervention will be included in the plan of care?

Correct Answer
verified

When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow, it is important to

Correct Answer
verified

When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to

Correct Answer
verified

The nurse is reviewing the charts for five patients who are scheduled for their yearly physical examinations in October. Which of the following patients will require the inactivated influenza vaccination (select all that apply) ?

Correct Answer
verified

The teaching plan for a patient with acute sinusitis will need to include which of the following interventions (select all that apply) ?

Correct Answer
verified
A, B, C, E

Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN/LVN who is caring for a patient with a permanent tracheostomy?

Correct Answer
verified

Which action should the nurse take first when a patient develops a nosebleed?

Correct Answer
verified

After discussing management of upper respiratory infections (URI) with a patient who has acute viral rhinitis, the nurse determines that additional teaching is needed when the patient says

Correct Answer
verified

A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?

Correct Answer
verified
A

A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective?

Correct Answer
verified

An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene?

Correct Answer
verified
B

The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to treat a nosebleed. Which of the following assessment findings will require the most immediate action by the nurse?

Correct Answer
verified

The nurse obtains the following assessment data in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider?

Correct Answer
verified

When the 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?

Correct Answer
verified

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "How will I talk after the surgery?" The best response by the nurse is,

Correct Answer
verified

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 is the best indicator that the problem identified in this nursing diagnosis is resolving?

Correct Answer
verified

Which of these patients in the respiratory disease clinic should the nurse assess first?

Correct Answer
verified

When teaching the patient with allergic rhinitis about management of the condition, the nurse explains that

Correct Answer
verified

After completing discharge instructions for a patient with a total laryngectomy, the nurse determines that additional instruction is needed when the patient says,

Correct Answer
verified

Exam 27: Nursing Management: Upper Respiratory Problems

Correct AnswerverifiedB, D, C, AThe patient should first be p...View AnswerShow Answer

After a patient has undergone a rhinoplasty, which nursing intervention will be included in the plan of care?

Correct AnswerverifiedShow Answer

When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow, it is important to

Correct AnswerverifiedShow Answer

When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to

Correct AnswerverifiedShow Answer

The nurse is reviewing the charts for five patients who are scheduled for their yearly physical examinations in October. Which of the following patients will require the inactivated influenza vaccination (select all that apply) ?

Correct AnswerverifiedShow Answer

The teaching plan for a patient with acute sinusitis will need to include which of the following interventions (select all that apply) ?

Correct AnswerverifiedA, B, C, E

Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN/LVN who is caring for a patient with a permanent tracheostomy?

Correct AnswerverifiedShow Answer

Which action should the nurse take first when a patient develops a nosebleed?

Correct AnswerverifiedShow Answer

After discussing management of upper respiratory infections (URI) with a patient who has acute viral rhinitis, the nurse determines that additional teaching is needed when the patient says

Correct AnswerverifiedShow Answer

A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?

Correct AnswerverifiedA

A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective?

Correct AnswerverifiedShow Answer

An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene?

Correct AnswerverifiedB

The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to treat a nosebleed. Which of the following assessment findings will require the most immediate action by the nurse?

Correct AnswerverifiedShow Answer

The nurse obtains the following assessment data in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider?

Correct AnswerverifiedShow Answer

When the 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?

Correct AnswerverifiedShow Answer

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "How will I talk after the surgery?" The best response by the nurse is,

Correct AnswerverifiedShow Answer

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 is the best indicator that the problem identified in this nursing diagnosis is resolving?

Correct AnswerverifiedShow Answer

Which of these patients in the respiratory disease clinic should the nurse assess first?

Correct AnswerverifiedShow Answer

When teaching the patient with allergic rhinitis about management of the condition, the nurse explains that

Correct AnswerverifiedShow Answer

After completing discharge instructions for a patient with a total laryngectomy, the nurse determines that additional instruction is needed when the patient says,

Correct AnswerverifiedShow Answer

Correct Answer
verified
B, D, C, A
The patient should first be p...
View Answer

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified
A, B, C, E

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified
A

Correct Answer
verified

Correct Answer
verified
B

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified