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Chapter 26: 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?
1. I can take 800 mg ibuprofen for pain control.
2. I will safely remove and reapply nasal packing daily.
3. My nose will look normal after 24 hours when the swelling goes away.
4. I will keep my head elevated for 48 hours to minimize swelling and pain.
ANS: D
2. The nurse plans to teach a patient how to manage allergic rhinitis. Which
information should the nurse include in the teaching plan?
1. Hand washing is the primary way to prevent spreading the condition to
others.
2. Use of oral antihistamines for 2 weeks before the allergy season may prevent
reactions.
3. Corticosteroid nasal sprays will reduce inflammation, but systemic effects
limit their use.
4. Identification and avoidance of environmental triggers are the best way to
avoid symptoms.
ANS: D
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?
1. I can take acetaminophen (Tylenol) to treat my discomfort.
2. I will drink lots of juices and other fluids to stay well hydrated.
3. I can use my nasal decongestant spray until the congestion is all gone.
4. I will watch for changes in nasal secretions or the sputum that I cough up.
ANS: C
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?
1. Encourage increased incentive spirometer use.
2. Encourage the patient to increase oral fluid intake.
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3. Put on sterile gloves and use a sterile catheter to suction.
4. Preoxygenate the patient for 3 minutes before suctioning.
ANS: C
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?
1. Leave the tracheostomy inner cannula inserted at all times.
2. Place the decannulation cap in the tube before cuff deflation.
3. Assess the ability to swallow before using the fenestrated tube.
4. d. Inflate the tracheostomy cuff during use of the fenestrated tube.
ANS: C
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?
1. Use a manometer to ensure cuff pressure is at an appropriate level.
2. Check the amount of cuff pressure ordered by the health care provider.
3. Suction the patient first with a fenestrated inner cannula to clear secretions.
4. Insert the decannulation plug before the nonfenestrated inner cannula is
removed.
ANS: A
7. Which statement by the patient indicates that the teaching has been effective for
a patient scheduled for radiation therapy of the larynx?
1. I will need to buy a water bottle to carry with me.
2. I should not use any lotions on my neck and throat.
3. Until the radiation is complete, I may have diarrhea.
4. Alcohol-based mouthwashes will help clean oral ulcers.
ANS: A
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?
1. How much alcohol do you drink in an average week?
2. Do you have a family history of head or neck cancer?
3. Have you had frequent streptococcal throat infections?
4. Do you use antihistamines for upper airway congestion?
ANS: A
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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 best response by the nurse?
1. You will breathe through a permanent opening in your neck, but you will not
be able to communicate orally.
2. You wont be able to talk right after surgery, but you will be able to speak
again after the tracheostomy tube is removed.
3. You wont be able to speak as you used to, but there are artificial voice devices
that will give you the ability to speak normally.
4. You will have a permanent opening into your neck, and you will need to have
rehabilitation for some type of voice restoration.
ANS: D
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
is the best indicator that this identified problem is resolving?
1. The patient lets the spouse provide tracheostomy care.
2. The patient allows the nurse to suction the tracheostomy.
3. The patient asks how to clean the tracheostomy stoma and tube.
4. The patient uses a communication board to request No Visitors.
ANS: C
11. The nurse completes discharge instructions for a patient with a total
laryngectomy. Which statement by the patient indicates that additional instruction
is needed?
1. I must keep the stoma covered with an occlusive dressing at all times.
2. I can participate in most of my prior fitness activities except swimming.
3. I should wear a Medic-Alert bracelet that identifies me as a neck breather.
4. I need to be sure that I have smoke and carbon monoxide detectors installed.
ANS: A
12. Which action should the nurse take first when a patient develops a nosebleed?
a. Pinch the lower portion of the nose for 10 minutes.
b. Pack the affected nare tightly with an epistaxis balloon.
c. Obtain silver nitrate that will be needed for cauterization.
d. Apply ice compresses over the patients nose and cheeks.
ANS: A
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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?
1. Monitor for bleeding.
2. Maintain adequate IV fluid intake.
3. Suction tracheostomy every eight hours.
4. Keep the patient in semi-Fowlers position.
ANS: D
14. Following a laryngectomy a patient coughs violently during suctioning and
dislodges the tracheostomy tube. Which action should the nurse take first?
a. Cover stoma with sterile gauze and ventilate through stoma.
b. Attempt to reinsert the tracheostomy tube with the obturator in place.
c. Assess the patients oxygen saturation and notify the health care provider.
d. Ventilate the patient with a manual bag and face mask until the health care
provider arrives.
ANS: B
15. Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess
first?
1. A 23-year-old who is complaining of a sore throat and has a muffled voice
2. A 34-year-old who has a scratchy throat and a positive rapid strep antigen
test
3. A 55-year-old who is receiving radiation for throat cancer and has severe
fatigue
4. A 72-year-old with a history of a total laryngectomy whose stoma is red and
inflamed
ANS: A
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?
1. Fever of 100.4 F (38 C)
2. Diffuse crackles in the lungs
3. Sore throat and frequent cough
4. Myalgia and persistent headache
ANS: B
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Chapter 26: 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?
1. I can take 800 mg ibuprofen for pain control.
2. I will safely remove and reapply nasal packing daily.
3. My nose will look normal after 24 hours when the swelling goes away.
4. I will keep my head elevated for 48 hours to minimize swelling and pain.
ANS: D
2. The nurse plans to teach a patient how to manage allergic rhinitis. Which
information should the nurse include in the teaching plan?
1. Hand washing is the primary way to prevent spreading the condition to
others.
2. Use of oral antihistamines for 2 weeks before the allergy season may prevent
reactions.
3. Corticosteroid nasal sprays will reduce inflammation, but systemic effects
limit their use.
4. Identification and avoidance of environmental triggers are the best way to
avoid symptoms.
ANS: D
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?
1. I can take acetaminophen (Tylenol) to treat my discomfort.
2. I will drink lots of juices and other fluids to stay well hydrated.
3. I can use my nasal decongestant spray until the congestion is all gone.
4. I will watch for changes in nasal secretions or the sputum that I cough up.
ANS: C
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?
1. Encourage increased incentive spirometer use.
2. Encourage the patient to increase oral fluid intake.
CLASSROOM CLASSROOM CLASSROOM
,CLASSROOM CLASSROOM CLASSROOM
3. Put on sterile gloves and use a sterile catheter to suction.
4. Preoxygenate the patient for 3 minutes before suctioning.
ANS: C
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?
1. Leave the tracheostomy inner cannula inserted at all times.
2. Place the decannulation cap in the tube before cuff deflation.
3. Assess the ability to swallow before using the fenestrated tube.
4. d. Inflate the tracheostomy cuff during use of the fenestrated tube.
ANS: C
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?
1. Use a manometer to ensure cuff pressure is at an appropriate level.
2. Check the amount of cuff pressure ordered by the health care provider.
3. Suction the patient first with a fenestrated inner cannula to clear secretions.
4. Insert the decannulation plug before the nonfenestrated inner cannula is
removed.
ANS: A
7. Which statement by the patient indicates that the teaching has been effective for
a patient scheduled for radiation therapy of the larynx?
1. I will need to buy a water bottle to carry with me.
2. I should not use any lotions on my neck and throat.
3. Until the radiation is complete, I may have diarrhea.
4. Alcohol-based mouthwashes will help clean oral ulcers.
ANS: A
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?
1. How much alcohol do you drink in an average week?
2. Do you have a family history of head or neck cancer?
3. Have you had frequent streptococcal throat infections?
4. Do you use antihistamines for upper airway congestion?
ANS: A
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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 best response by the nurse?
1. You will breathe through a permanent opening in your neck, but you will not
be able to communicate orally.
2. You wont be able to talk right after surgery, but you will be able to speak
again after the tracheostomy tube is removed.
3. You wont be able to speak as you used to, but there are artificial voice devices
that will give you the ability to speak normally.
4. You will have a permanent opening into your neck, and you will need to have
rehabilitation for some type of voice restoration.
ANS: D
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
is the best indicator that this identified problem is resolving?
1. The patient lets the spouse provide tracheostomy care.
2. The patient allows the nurse to suction the tracheostomy.
3. The patient asks how to clean the tracheostomy stoma and tube.
4. The patient uses a communication board to request No Visitors.
ANS: C
11. The nurse completes discharge instructions for a patient with a total
laryngectomy. Which statement by the patient indicates that additional instruction
is needed?
1. I must keep the stoma covered with an occlusive dressing at all times.
2. I can participate in most of my prior fitness activities except swimming.
3. I should wear a Medic-Alert bracelet that identifies me as a neck breather.
4. I need to be sure that I have smoke and carbon monoxide detectors installed.
ANS: A
12. Which action should the nurse take first when a patient develops a nosebleed?
a. Pinch the lower portion of the nose for 10 minutes.
b. Pack the affected nare tightly with an epistaxis balloon.
c. Obtain silver nitrate that will be needed for cauterization.
d. Apply ice compresses over the patients nose and cheeks.
ANS: A
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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?
1. Monitor for bleeding.
2. Maintain adequate IV fluid intake.
3. Suction tracheostomy every eight hours.
4. Keep the patient in semi-Fowlers position.
ANS: D
14. Following a laryngectomy a patient coughs violently during suctioning and
dislodges the tracheostomy tube. Which action should the nurse take first?
a. Cover stoma with sterile gauze and ventilate through stoma.
b. Attempt to reinsert the tracheostomy tube with the obturator in place.
c. Assess the patients oxygen saturation and notify the health care provider.
d. Ventilate the patient with a manual bag and face mask until the health care
provider arrives.
ANS: B
15. Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess
first?
1. A 23-year-old who is complaining of a sore throat and has a muffled voice
2. A 34-year-old who has a scratchy throat and a positive rapid strep antigen
test
3. A 55-year-old who is receiving radiation for throat cancer and has severe
fatigue
4. A 72-year-old with a history of a total laryngectomy whose stoma is red and
inflamed
ANS: A
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?
1. Fever of 100.4 F (38 C)
2. Diffuse crackles in the lungs
3. Sore throat and frequent cough
4. Myalgia and persistent headache
ANS: B
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