A&E II EXAM 1 TEST BANK.DOCX
Chapter 27: Nursing Management: Upper Respiratory Problems
Test Bank
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?
a. “I can take 800 mg ibuprofen for pain control.”
b. “I will safely remove and reapply nasal packing daily.”
c. “My nose will look normal after 24 hours when the swelling goes away.”
d. “I will keep my head elevated for 48 hours to minimize swelling and pain.”
ANS: D
Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs, such as ibuprofen, increase the risk
for postoperative bleeding and should not be used postoperatively. The patient would not be taught to 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.
2. The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan?
a. Hand washing is the primary way to prevent spreading the condition to others.
b. Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions.
c. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.
d. Identification and avoidance of environmental triggers are the best way to avoid symptoms.
ANS: D
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 (the common cold) can be prevented by washing hands.
3. The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by
the patient indicates that additional teaching is needed?
a. “I can take acetaminophen (Tylenol) to treat my discomfort.”
b. “I will drink lots of juices and other fluids to stay well 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.”
ANS: C
The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and
1
, A&E II EXAM 1 TEST BANK.DOCX
congestion. The other responses indicate that the teaching has been effective.
2
,DIF: Cognitive Level: Apply (application) REF:
A&E502 II EXAM 1 TEST BANK.DOCX
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
4. A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. 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. Incentive spirometer (IS) 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: 510
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?
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.
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: 511
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 best determine if the cuff has been properly inflated?
a. Use a manometer to ensure cuff pressure is at an appropriate level.
b. Check the amount of cuff pressure ordered by the health care provider.
c. Suction the patient first with a fenestrated inner cannula to clear secretions.
3
, d. A&E II EXAM 1 TEST BANK.DOCX
e. Insert the decannulation plug before the nonfenestrated inner cannula is removed.
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: 509
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
7. Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the
larynx?
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.”
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: 515-516
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 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?”
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. Streptococcal throat infections also
may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever.
DIF: Cognitive Level: Apply (application) REF: 515
4
Chapter 27: Nursing Management: Upper Respiratory Problems
Test Bank
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?
a. “I can take 800 mg ibuprofen for pain control.”
b. “I will safely remove and reapply nasal packing daily.”
c. “My nose will look normal after 24 hours when the swelling goes away.”
d. “I will keep my head elevated for 48 hours to minimize swelling and pain.”
ANS: D
Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs, such as ibuprofen, increase the risk
for postoperative bleeding and should not be used postoperatively. The patient would not be taught to 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.
2. The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan?
a. Hand washing is the primary way to prevent spreading the condition to others.
b. Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions.
c. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.
d. Identification and avoidance of environmental triggers are the best way to avoid symptoms.
ANS: D
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 (the common cold) can be prevented by washing hands.
3. The nurse discusses management of upper respiratory infections (URI) with a patient who has acute sinusitis. Which statement by
the patient indicates that additional teaching is needed?
a. “I can take acetaminophen (Tylenol) to treat my discomfort.”
b. “I will drink lots of juices and other fluids to stay well 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.”
ANS: C
The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and
1
, A&E II EXAM 1 TEST BANK.DOCX
congestion. The other responses indicate that the teaching has been effective.
2
,DIF: Cognitive Level: Apply (application) REF:
A&E502 II EXAM 1 TEST BANK.DOCX
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
4. A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. 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. Incentive spirometer (IS) 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: 510
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?
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.
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: 511
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 best determine if the cuff has been properly inflated?
a. Use a manometer to ensure cuff pressure is at an appropriate level.
b. Check the amount of cuff pressure ordered by the health care provider.
c. Suction the patient first with a fenestrated inner cannula to clear secretions.
3
, d. A&E II EXAM 1 TEST BANK.DOCX
e. Insert the decannulation plug before the nonfenestrated inner cannula is removed.
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: 509
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
7. Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the
larynx?
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.”
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: 515-516
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 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?”
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. Streptococcal throat infections also
may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever.
DIF: Cognitive Level: Apply (application) REF: 515
4
