Question 1

After a posterior nasal pack is inserted by the physician, the client is very anxious and states, "I don't feel like I'm breathing right." The immediate intervention the nurse would initiate is

Accepted Answer

A)   collect a specimen for arterial blood gases (ABGs) .
B)   cut the pack strings and pull the packing out.
C)   inspect the client's oral cavity using a flashlight.
D)   reassure the client that this is normal discomfort.E) A) and D)
F) None of the above

Question 2

In the preoperative teaching plan for a client scheduled for total laryngectomy and radical neck resection, the nurse would give highest priority to the

Accepted Answer

A)   client not being able to perform deep-breathing exercises.
B)   client not being able to speak normally again.
C)   endotracheal tube being in place for 2 to 3 days.
D)   insertion of a gastrostomy tube during surgery for feeding.E) All of the above
F) A) and D) B

Question 3

When a client coughs violently and the tracheostomy tube falls out, the client becomes dyspneic and the nurse attempts to reinsert the tracheostomy tube over the next 60 seconds but is unable to do so. The nurse's next action would be

Accepted Answer

A)   call a code.
B)   perform a cricoidectomy.
C)   place a finger in the stoma.
D)   start oxygen via nasal prongs.E) None of the above
F) C) and D)

Question 4

Noting the need to use 8 ml rather than 5 ml to inflate the tracheostomy cuff sufficiently, the nurse would

Accepted Answer

A)   ask the client to swallow, and then cough.
B)   completely deflate the cuff to relieve the dilation.
C)   notify the physician to have an x-ray film obtained.
D)   replace the entire tracheostomy tube with a larger size.E) A) and B)
F) B) and C)

Question 5

The priority nursing intervention for a client experiencing a laryngospasm would be

Accepted Answer

A)   administering 100% oxygen.
B)   calling the resuscitation team.
C)   positioning the client in high-Fowler position.
D)   starting in IV with a large-bore catheter.E) None of the above
F) A) and D)

Question 6

A client is in the recovery room after surgical removal of nasal polyps. The nurse notices the client is swallowing frequently. The most appropriate action by the nurse is to

Accepted Answer

A)   assess the client's mouth for blood.
B)   continue to monitor and assess the client.
C)   notify the physician immediately.
D)   turn the client on the left side.E) A) and B)
F) All of the above A

Question 7

The measure that would best aid the nurse in removing heavy, tenacious secretions during suctioning is

Accepted Answer

A)   encouraging frequent coughing and deep breathing.
B)   employing postural drainage before suctioning.
C)   hyperinflating the lungs before suctioning.
D)   instilling sterile saline directly into the trachea.E) All of the above
F) None of the above

Question 8

The spouse of a client who is receiving mechanical ventilation via tracheostomy asks why his wife cannot have a tracheostomy button. The nurse's most informative response would be

Accepted Answer

A)   "A button cannot be used with a ventilator."
B)   "Buttons make the work of breathing harder."
C)   "Suctioning can't be done with buttons."
D)   "That would decrease your wife's oxygenation."E) A) and B)
F) C) and D)

Question 9

When feeding a client with a tracheostomy, the nurse would

Accepted Answer

A)   follow each spoon of food with liquid.
B)   have the client in an upright sitting position.
C)   inflate the cuff before the meal.
D)   thin the food to liquid consistency.E) A) and C)
F) All of the above

Question 10

Which intervention would probably help most when teaching a client to speak again after a laryngectomy?

Accepted Answer

A)   Give the client contact information so speech therapy can continue at home.
B)   Help the client and family understand that this is a frustrating experience.
C)   Make sure the client has a supply of paper and pens.
D)   Obtain several different speaking aids for the client to try at home.E) All of the above
F) A) and B)

Question 11

When a friend comes to the nurse's apartment to seek help to stop the bleeding from a broken nose, the nurse would attempt to convince the friend to seek treatment in the emergency department primarily because

Accepted Answer

A)   cosmetic results are poor when treatment is delayed.
B)   general anesthesia may be needed to locate the bleeding vessels.
C)   it will be very difficult to stop the bleeding if the nose is fractured.
D)   the nose cannot be set for 2 to 3 days if edema develops.E) All of the above
F) B) and C)

Question 12

A busy nurse in the ICU wishes to delegate aspects of respiratory care to an unlicensed assistive personnel (UAP) . Which of the following actions can the nurse delegate? (Select all that apply.)

Accepted Answer

A)   Measuring and recording oxygen saturations
B)   Setting up oxygen delivery and suction equipment
C)   Suctioning secretions of a client with a long-standing tracheostomy
D)   Teaching the client how to cough with a tracheostomy
E)   Verifying that the correct amount of oxygen is being deliveredF) A) and C)
G) D) and E)

Question 13

For a client who has undergone functional endoscopic sinus surgery (FESS)  as part of the surgical management of sinusitis, the nurse would instruct the client

Accepted Answer

A)   "Don't blow your nose for 1 week."
B)   "Eat only semi-solid foods."
C)   "Lean forward when eating."
D)   "Limit the amount of fluids you drink."E) A) and C)
F) C) and D)

Question 14

During a community screening event, the nurse would identify that the client at highest risk for development of laryngeal cancer is

Accepted Answer

A)   a 30-year-old man who smokes one pack of cigarettes per day.
B)   a 60-year-old woman who smokes occasionally and is easily fatigued.
C)   a 70-year-old man with a 40-year history of alcohol use and heavy smoking.
D)   an 80-year-old man who has a very high intake of caffeinated beverages.E) A) and D)
F) B) and C)

Question 15

A client is trying unsuccessfully to clear the airway with a cough. The measure the nurse would suggest to help the client cough more effectively is

Accepted Answer

A)   cough while leaning forward.
B)   drink milk to coat the throat.
C)   insert a large-lumen suction catheter before coughing.
D)   place a clean finger over the tracheostomy tube and cough.E) A) and B)
F) B) and C)

Question 16

The nurse working with a client who has acute sinusitis plans to teach the client about the routinely-used treatments for this condition, which include (Select all that apply)

Accepted Answer

A)   antibiotics.
B)   antihistamines.
C)   mucolytic agents.
D)   oral alpha-adrenergic vasoconstrictors.E) B) and C)
F) None of the above

Question 17

A neighbor tells a nurse that s/he has been experiencing hoarseness for over 3 weeks. The nurse should advise the client to see a doctor for

Accepted Answer

A)   a prescription for antacids.
B)   possible laryngeal cancer.
C)   throat cultures and antibiotics.
D)   vocal cord paralysis.E) All of the above
F) C) and D) B

Question 18

A client recently had a total laryngectomy and plans to use an artificial larynx for speech. The common problem the nurse would address regarding the artificial larynx is that

Accepted Answer

A)   it is a device that is difficult to use.
B)   it has a masculine-sounding voice quality.
C)   it has a monotone speech quality.
D)   it causes neck discomfort.E) B) and D)
F) B) and C)

Question 19

A client has frequent bouts of laryngitis. When assessing the client the nurse should specifically ask questions regarding the presence of

Accepted Answer

A)   a family history of idiopathic hoarseness.
B)   frequent upper respiratory tract infections.
C)   gastroesophageal reflux disorder.
D)   a history of stomach cancer.E) None of the above
F) A) and D)

Question 20

For an elderly client who has a posterior nasal plug and anterior nasal packing in place to control an episode of severe epistaxis, the priority assessment for the nurse would be assessing for

Accepted Answer

A)   continuing nasal pain.
B)   dislodged packing.
C)   presence of hypoxia.
D)   swallowing blood.E) A) and B)
F) None of the above

Exam 60: Management of Clients with Upper Airway Disorders

After a posterior nasal pack is inserted by the physician, the client is very anxious and states, "I don't feel like I'm breathing right." The immediate intervention the nurse would initiate is

Correct AnswerverifiedShow Answer

In the preoperative teaching plan for a client scheduled for total laryngectomy and radical neck resection, the nurse would give highest priority to the

Correct AnswerverifiedB

When a client coughs violently and the tracheostomy tube falls out, the client becomes dyspneic and the nurse attempts to reinsert the tracheostomy tube over the next 60 seconds but is unable to do so. The nurse's next action would be

Correct AnswerverifiedShow Answer

Noting the need to use 8 ml rather than 5 ml to inflate the tracheostomy cuff sufficiently, the nurse would

Correct AnswerverifiedShow Answer

The priority nursing intervention for a client experiencing a laryngospasm would be

Correct AnswerverifiedShow Answer

A client is in the recovery room after surgical removal of nasal polyps. The nurse notices the client is swallowing frequently. The most appropriate action by the nurse is to

Correct AnswerverifiedA

The measure that would best aid the nurse in removing heavy, tenacious secretions during suctioning is

Correct AnswerverifiedShow Answer

The spouse of a client who is receiving mechanical ventilation via tracheostomy asks why his wife cannot have a tracheostomy button. The nurse's most informative response would be

Correct AnswerverifiedShow Answer

When feeding a client with a tracheostomy, the nurse would

Correct AnswerverifiedShow Answer

Which intervention would probably help most when teaching a client to speak again after a laryngectomy?

Correct AnswerverifiedShow Answer

When a friend comes to the nurse's apartment to seek help to stop the bleeding from a broken nose, the nurse would attempt to convince the friend to seek treatment in the emergency department primarily because

Correct AnswerverifiedShow Answer

A busy nurse in the ICU wishes to delegate aspects of respiratory care to an unlicensed assistive personnel (UAP) . Which of the following actions can the nurse delegate? (Select all that apply.)

Correct AnswerverifiedShow Answer

For a client who has undergone functional endoscopic sinus surgery (FESS) as part of the surgical management of sinusitis, the nurse would instruct the client

Correct AnswerverifiedShow Answer

During a community screening event, the nurse would identify that the client at highest risk for development of laryngeal cancer is

Correct AnswerverifiedShow Answer

A client is trying unsuccessfully to clear the airway with a cough. The measure the nurse would suggest to help the client cough more effectively is

Correct AnswerverifiedShow Answer

The nurse working with a client who has acute sinusitis plans to teach the client about the routinely-used treatments for this condition, which include (Select all that apply)

Correct AnswerverifiedShow Answer

A neighbor tells a nurse that s/he has been experiencing hoarseness for over 3 weeks. The nurse should advise the client to see a doctor for

Correct AnswerverifiedB

A client recently had a total laryngectomy and plans to use an artificial larynx for speech. The common problem the nurse would address regarding the artificial larynx is that

Correct AnswerverifiedShow Answer

A client has frequent bouts of laryngitis. When assessing the client the nurse should specifically ask questions regarding the presence of

Correct AnswerverifiedShow Answer

For an elderly client who has a posterior nasal plug and anterior nasal packing in place to control an episode of severe epistaxis, the priority assessment for the nurse would be assessing for

Correct AnswerverifiedShow Answer

Correct Answer
verified

Correct Answer
verified
B

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified
A

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified
B

Correct Answer
verified

Correct Answer
verified

Correct Answer
verified