Infectious Respiratory Problems, Correctly Answered
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1. A client has acute rhinitis. What is the most important intervention for the nurse to
perform?
a. Assess for symptoms of infection.
b. Ascertain whether the client has allergies.
c. Question the client on the use of nasal sprays.
d. Do blood and urine screenings for drug use.
ANSWER: A
Bacterial infection often occurs with acute rhinitis. The nurse should assess for
symptoms because treatment may be warranted. It is not essential to assess for
allergies or the use of nasal spray, or to determine whether drug use is occurring. All of
these interventions are focused on determining a cause for repeated acute rhinitis and
are primarily the responsibility of the health care provider. The nurse should focus on
client assessment and should determine whether a secondary infection is present.
2. A client has pharyngitis. Which symptom helps the nurse determine whether the
infection is bacterial versus viral?
a. Redness in the back of the throat
b. Enlarged lymph glands in the neck
c. Nasal discharge
,d. Skin rash
ANSWER: D
Generally a rash can appear with bacterial pharyngitis, but not with viral. The other
symptoms are characteristic of both.
3. It is suspected that a client has bacterial pharyngitis. What is the best intervention?
a. Administer a broad-spectrum antibiotic.
b. Have the client produce a sputum specimen.
c. Obtain samples for culture and sensitivity.
d. Assess a rapid antigen test (RAT).
ANSWER: D
A common cause of bacterial pharyngitis is group A streptococcal virus, which can lead
to serious complications. Both RATs and culture and sensitivity can diagnose this
bacterium; however, with an RAT, the health care provider can obtain results in about
15 minutes, and definitive treatment can begin much sooner. A broad-spectrum
antibiotic would not be administered before it was determined whether the infection
was bacterial. A sputum specimen is needed for lung infection but not for throat
infection.
4. The nurse is caring for a client with recurrent bacterial pharyngitis. Which is the
nurse's highest priority intervention?
a. Assess for symptoms of human immune deficiency virus (HIV).
b. Ask about exposure to allergens.
c. Perform nasal cultures.
d. Teach the client about antibiotic therapy.
, ANSWER: D
Management of bacterial pharyngitis involves the use of antibiotics and the same
supportive care provided for viral pharyngitis. Stress the importance of completing the
entire antibiotic prescription, even when symptoms improve or subside. Failure to take
all prescribed antibiotics is often the cause of recurrent infections. Although it is
important for overall health that the client know his or her HIV status, it is not the
highest priority intervention in the treatment plan. Allergens do not cause bacterial
infections. Nasal cultures would not be a high priority unless the client had "failed"
treatment with more than one antibiotic and was compliant with treatment.
5. A client who has had acute tonsillitis develops drooling and reports severe throat
pain. What is the nurse's priority intervention?
a. Assess the throat for deviation of the uvula.
b. Prepare the client for surgery.
c. Teach the client about antibiotic therapy.
d. Prepare the client for percutaneous needle aspiration.
ANSWER: A
The nurse should first assess the throat for signs of peritonsillar abscess. If present, the
nurse should call the health care provider immediately because aspiration of the
abscess may be needed to maintain the airway.
6. The nurse has determined that a client has an acute sore throat. What is the nurse's
best action?
a. Assess whether the client can speak.
b. Call an ear-nose-throat specialist.
c. Administer an antibiotic.
d. Give the client ice chips.