Chapter 26: Concepts of Care for Patients
with Non-infectious Upper Respiratory
Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse cares for a client who is scheduled for a total laryngectomy. What action
would the nurse take prior to surgery?
a. Assess airway patency, breathing, and circulation.
b. Administer prescribed intravenous pain medication.
c. Assist the client to choose a communication method.
d. Ambulate the client in the hallway to assess gait.
ANS: C
The client will not be able to speak after surgery. The nurse would assist the client to
choose a communication method that he or she would like to use after surgery.
Assessing the patient’s airway and administering IV pain medication are done after
the procedure. Although ambulation promotes health and decreases the complications
of any surgery, this patient’s gait would not be impacted by a total laryngectomy and
therefore is not a priority.
DIF: Applying TOP: Integrated Process: Caring KEY: Surgical
care, Communication MSC: Client Needs Category: Psychosocial Integrity
2. While assessing a client who has facial trauma, the nurse auscultates stridor. The
client is anxious and restless. What action would the nurse take first?
, a. Contact the primary health care provider and prepare for intubation.
b. Administer prescribed albuterol nebulizer therapy.
c. Place the client in high-Fowler position.
d. Ask the client to perform deep-breathing exercises.
ANS: A
Facial and neck tissue edema can occur in clients with facial trauma. Airway patency
is the highest priority. Clients who experience stridor and hypoxia, manifested by
anxiety and restlessness, would be immediately intubated to ensure airway patency.
Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema.
Although putting the client in high-Fowler position and asking the client to perform
breathing exercises may temporarily improve the patient’s comfort, these actions will
not decrease the underlying problem or improve airway patency.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Trauma, Airway MSC: Client Needs Category:
Physiological Integrity: Physiological Adaptation
3. A nurse cares for a client who has packing inserted for posterior nasal bleeding. What
action would the nurse take first?
a. Assess the client’s pain level.
b. Keep the client’s head elevated.
c. Teach the client about the causes of nasal bleeding.
d. Assess the client’s airway.
ANS: D
If the packing slips out of place, it may obstruct the client’s airway. The other options
are good interventions, but ensuring that the airway is patent in the priority objective.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Epistaxis, Airway MSC: Client Needs
Category: Safe and Effective Care Environment: Management of Care
with Non-infectious Upper Respiratory
Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse cares for a client who is scheduled for a total laryngectomy. What action
would the nurse take prior to surgery?
a. Assess airway patency, breathing, and circulation.
b. Administer prescribed intravenous pain medication.
c. Assist the client to choose a communication method.
d. Ambulate the client in the hallway to assess gait.
ANS: C
The client will not be able to speak after surgery. The nurse would assist the client to
choose a communication method that he or she would like to use after surgery.
Assessing the patient’s airway and administering IV pain medication are done after
the procedure. Although ambulation promotes health and decreases the complications
of any surgery, this patient’s gait would not be impacted by a total laryngectomy and
therefore is not a priority.
DIF: Applying TOP: Integrated Process: Caring KEY: Surgical
care, Communication MSC: Client Needs Category: Psychosocial Integrity
2. While assessing a client who has facial trauma, the nurse auscultates stridor. The
client is anxious and restless. What action would the nurse take first?
, a. Contact the primary health care provider and prepare for intubation.
b. Administer prescribed albuterol nebulizer therapy.
c. Place the client in high-Fowler position.
d. Ask the client to perform deep-breathing exercises.
ANS: A
Facial and neck tissue edema can occur in clients with facial trauma. Airway patency
is the highest priority. Clients who experience stridor and hypoxia, manifested by
anxiety and restlessness, would be immediately intubated to ensure airway patency.
Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema.
Although putting the client in high-Fowler position and asking the client to perform
breathing exercises may temporarily improve the patient’s comfort, these actions will
not decrease the underlying problem or improve airway patency.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Trauma, Airway MSC: Client Needs Category:
Physiological Integrity: Physiological Adaptation
3. A nurse cares for a client who has packing inserted for posterior nasal bleeding. What
action would the nurse take first?
a. Assess the client’s pain level.
b. Keep the client’s head elevated.
c. Teach the client about the causes of nasal bleeding.
d. Assess the client’s airway.
ANS: D
If the packing slips out of place, it may obstruct the client’s airway. The other options
are good interventions, but ensuring that the airway is patent in the priority objective.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Epistaxis, Airway MSC: Client Needs
Category: Safe and Effective Care Environment: Management of Care
