Chapter 25: Respiratory System Introduction
Linton: Medical-Surgical Nursing, 7th Edition
MULTIPLE CHOICE
1. What portion of the internal nose traps particles and kills bacteria?
a. Turbinates
b. Mucous membrane
c. Vestibular formations
d. Cilia
ANS: B
The mucous membrane traps particles and bacteria that are inhaled; then an enzyme in the
mucus destroys them. The cilia then sweep the particles into the throat to be swallowed.
DIF: Cognitive Level: Knowledge REF: p. 440 OBJ: 1
TOP: Anatomy and Physiology of the Nose
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. A patient comes into the clinic complaining of a runny nose and facial pain. What should the
nurse’s initial assessment include?
a. Assessment for nasal drainage and sinus tenderness
b. Transillumination and nasal speculum examination
c. Palpation of the frontal and maxillary sinuses and tonsillar inspection
d. Turbinate assessment and assessment for patency of the nares
ANS: A
The assessment of the characteristics of the nasal drainage and location of the facial pain
would be the first evaluation for sinusitis.
DIF: Cognitive Level: Application REF: pp. 443-444 OBJ: 2
TOP: Physical Examination of the Nose KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. A 68-year-old patient tells the nurse that her sense of smell is not as acute as before, her nose
is drier, and she occasionally gets a nosebleed. What should the nurse suspect?
a. An infection
b. Normal age-related changes
c. A nasal defect
d. Allergies that are causing her symptoms
ANS: B
These options describe normal age-related changes. A suggestion that would make the patient
more comfortable would be to use a humidifier to keep the mucous membranes moist.
DIF: Cognitive Level: Application REF: p. 443 OBJ: 2
TOP: Age-Related Changes in the Nose and Sinuses
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
, 4. What does age-related relaxation of the esophageal sphincter in a 70-year-old patient cause?
a. Excessive belching
b. Dumping syndrome
c. Tickling sensation, requiring frequent coughing
d. Burning in the throat when lying down
ANS: D
A common age-related change in the throat is a weakened esophageal sphincter. This allows
gastric contents to flow back up into the throat and irritate the larynx. Elevating the head of
the bed is a common treatment.
DIF: Cognitive Level: Comprehension REF: p. 442 OBJ: 4
TOP: Age-Related Changes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. When a patient with sleep apnea says, “I’m not wearing that silly mask. I look like something
out of Star Wars,” what should the nurse remind the patient about the function of the mask?
a. Increases oxygen intake
b. Stimulates regular respirations
c. Sounds an alarm when the oxygen concentration drops
d. Uses positive pressure to keep the airway open
ANS: D
The sleep apnea mask, through positive pressure, keeps the airway open during sleep.
DIF: Cognitive Level: Comprehension REF: p. 463 OBJ: 4
TOP: Sleep Apnea Mask KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
6. What should patient education for a patient being given nose drops for the first time include?
a. Asking the patient to sit down and tip her head to the side to allow for a better
angle for the instillation of the drops
b. Holding the dropper against the side of the nose so that all the medication flows
into the nares
c. Asking the patient to return any unused medication to the bottle
d. Tipping the head back and holding the dropper over the nostril and then telling the
patient to keep her head back for a few minutes
ANS: D
Appropriate instillation of nose drops requires that the head be tipped back and the bottle not
touch the nose.
DIF: Cognitive Level: Comprehension REF: p. 453 OBJ: 3
TOP: Nose Drops KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. A patient comes into the clinic complaining of waking up with a dry mouth and nose and asks
if the dryness has caused the colds she has had in the past few months. What is the most
appropriate suggestion for the nurse to suggest?
a. Use a humidifier at home.
b. Get a throat culture.
c. Get a nose culture.
Linton: Medical-Surgical Nursing, 7th Edition
MULTIPLE CHOICE
1. What portion of the internal nose traps particles and kills bacteria?
a. Turbinates
b. Mucous membrane
c. Vestibular formations
d. Cilia
ANS: B
The mucous membrane traps particles and bacteria that are inhaled; then an enzyme in the
mucus destroys them. The cilia then sweep the particles into the throat to be swallowed.
DIF: Cognitive Level: Knowledge REF: p. 440 OBJ: 1
TOP: Anatomy and Physiology of the Nose
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. A patient comes into the clinic complaining of a runny nose and facial pain. What should the
nurse’s initial assessment include?
a. Assessment for nasal drainage and sinus tenderness
b. Transillumination and nasal speculum examination
c. Palpation of the frontal and maxillary sinuses and tonsillar inspection
d. Turbinate assessment and assessment for patency of the nares
ANS: A
The assessment of the characteristics of the nasal drainage and location of the facial pain
would be the first evaluation for sinusitis.
DIF: Cognitive Level: Application REF: pp. 443-444 OBJ: 2
TOP: Physical Examination of the Nose KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. A 68-year-old patient tells the nurse that her sense of smell is not as acute as before, her nose
is drier, and she occasionally gets a nosebleed. What should the nurse suspect?
a. An infection
b. Normal age-related changes
c. A nasal defect
d. Allergies that are causing her symptoms
ANS: B
These options describe normal age-related changes. A suggestion that would make the patient
more comfortable would be to use a humidifier to keep the mucous membranes moist.
DIF: Cognitive Level: Application REF: p. 443 OBJ: 2
TOP: Age-Related Changes in the Nose and Sinuses
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
, 4. What does age-related relaxation of the esophageal sphincter in a 70-year-old patient cause?
a. Excessive belching
b. Dumping syndrome
c. Tickling sensation, requiring frequent coughing
d. Burning in the throat when lying down
ANS: D
A common age-related change in the throat is a weakened esophageal sphincter. This allows
gastric contents to flow back up into the throat and irritate the larynx. Elevating the head of
the bed is a common treatment.
DIF: Cognitive Level: Comprehension REF: p. 442 OBJ: 4
TOP: Age-Related Changes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. When a patient with sleep apnea says, “I’m not wearing that silly mask. I look like something
out of Star Wars,” what should the nurse remind the patient about the function of the mask?
a. Increases oxygen intake
b. Stimulates regular respirations
c. Sounds an alarm when the oxygen concentration drops
d. Uses positive pressure to keep the airway open
ANS: D
The sleep apnea mask, through positive pressure, keeps the airway open during sleep.
DIF: Cognitive Level: Comprehension REF: p. 463 OBJ: 4
TOP: Sleep Apnea Mask KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
6. What should patient education for a patient being given nose drops for the first time include?
a. Asking the patient to sit down and tip her head to the side to allow for a better
angle for the instillation of the drops
b. Holding the dropper against the side of the nose so that all the medication flows
into the nares
c. Asking the patient to return any unused medication to the bottle
d. Tipping the head back and holding the dropper over the nostril and then telling the
patient to keep her head back for a few minutes
ANS: D
Appropriate instillation of nose drops requires that the head be tipped back and the bottle not
touch the nose.
DIF: Cognitive Level: Comprehension REF: p. 453 OBJ: 3
TOP: Nose Drops KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. A patient comes into the clinic complaining of waking up with a dry mouth and nose and asks
if the dryness has caused the colds she has had in the past few months. What is the most
appropriate suggestion for the nurse to suggest?
a. Use a humidifier at home.
b. Get a throat culture.
c. Get a nose culture.
