ATI Care of Patients with Noninfectious Upper Respiratory Problems, Questions and Answers with Explanations, 100% Correct, Download to Score A

Test Bank

MULTIPLE CHOICE

1. A high school athlete has suffered a nasal fracture. What is the priority action of the nurse caring for the client?

a.            Assess for pain.

b.            Pack the nares to prevent blood loss.

c.             Assess for bone displacement.

d.            Assess for airway patency.

ANS: D

A patent airway is the priority. The nurse first should make sure that the airway is patent, then should determine whether the client is in pain, and whether bone displacement or blood loss has occurred.

DIF: Cognitive Level: Application/Applying or higher

TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

2. After facial trauma, a client has a nasal fracture and is reporting constant nasal drainage, a headache, and difficulty with vision. What is the nurse’s first action?

a.            Collect the nasal drainage on a piece of filter paper.

b.            Send the client for a facial x-ray.

c.             Perform a vision test.

d.            Palpate all facial areas for crepitus.

ANS: A

The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebral spinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the client’s risk for infection.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

3. What is the nurse’s most important action after a client’s gag reflex has returned post rhinoplasty?

a.            Teach the client to change position every 2 hours.

b.            Tell the client to put heating pads on the face.

c.             Instruct the client to lay flat.

d.            Have the client drink at least 2500 mL/day.

ANS: D

Once the gag reflex has returned, the client should drink at least 2 1/2 liters per day. The client should not change position frequently; the best position is semi-Fowler’s. Ice rather than heat should be applied. Lying flat is not recommended.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

4. A client reports waking up feeling very tired, even after 8 hours of good sleep. What is the nurse’s best action?

a.            Ask for an order for sleep medication.

b.            Tell the client not to drink beverages with caffeine.

c.             Tell the client not to lie flat at night.

d.            Ask the client whether he or she has ever been evaluated for sleep apnea.

ANS: D

Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

5. A client had a partial laryngectomy and has received instructions on the supraglottic method of swallowing. Which action by the nurse is most appropriate?

a.            Place a chart in the client’s room detailing the steps in the process.

b.            Order a dynamic swallow study.

c.             Repeat the instruction each day.

d.            Have the client demonstrate swallowing.

ANS: A

The client who is status post partial laryngectomy should be taught alternative methods of swallowing, and a chart should be placed in the client’s room to reinforce teaching. A dynamic swallow study is performed to guide rehabilitation for swallowing. Repeating the steps each shift is not as effective as showing the client a chart. Having the client demonstrate swallowing may not verify that he or she correctly understands supraglottic swallowing. A chart in the room will be most effective in helping both client and staff with this method.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

6. A client has open vocal cord paralysis. Which technique does the nurse teach the client to do to prevent aspiration?

a.            Tilt the head back as far as possible when swallowing.

b.            Tuck the chin down when swallowing.

c.             Breathe slowly and deeply while swallowing.

d.            Keep the head very still and straight while swallowing.

ANS: B

The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration, but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

7. Which client does the nurse safely delegate to the LPN/LVN who has been assigned to the unit for the first time?

a.            Young adult who is 6 hours post radical neck dissection

b.            Older adult client with esophageal cancer who is awaiting gastric tube placement

c.             Client who is status post laryngectomy and is awaiting discharge teaching

d.            Client who is awaiting preoperative teaching for laryngeal cancer

ANS: B

The nurse can delegate stable clients to the LPN. The client who is 6 hours post surgery is not yet stable. The RN is the only one who can perform discharge and preoperative teaching. Teaching cannot be delegated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Delegation) MSC: Integrated Process: Teaching/Learning

8. A client has a closed fracture of the nose. Which intervention is best when encouraging self-care for this client?

a.            Advise the client not to eat or drink for 24 hours after sustaining the fracture.

b.            Teach the client how to apply cold compresses to the area to reduce swelling.

c.             Urge the client to sleep without a pillow to hasten resolution of the swelling.

d.            Reassure the client that his or her appearance will normalize after the swelling is gone.

ANS: B

After a closed fracture of the nose, the nurse will encourage rest and the use of cool compresses on the nose, eyes, or face to help reduce swelling and bruising. Avoiding eating or drinking and sleeping without a pillow will not hasten resolution of the swelling. Reassuring the client regarding his or her appearance is not included in self-care.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

9. Which statement indicates that the client needs more teaching regarding rhinoplasty?

a.            “I will take my temperature twice each day and will report any fever to my doctor.”

b.            “I will wait a few weeks to have my photograph taken, when the swelling is gone.”

c.             “I will take acetaminophen instead of aspirin for pain to avoid excessive bleeding.”

d.            “I will drink at least 3 quarts of liquids a day and will use a stool softener.”

ANS: B

Explain that edema and bruising may last for weeks, and that the final surgical result will be evident in 6 to 12 months. The client should take his or her temperature and report fever in case of infection. The client should take acetaminophen because risk of bleeding is less than with aspirin. Fluids and stool softeners will decrease the risk of straining.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

10. What is the highest priority for the nurse to teach the client who is being discharged after a fixed centric occlusion for a mandibular fracture?

a.            How to use wire cutters

b.            Eating six soft or liquid meals each day

c.             How to irrigate the mouth every 2 hours

d.            Sleeping in semi-Fowler’s position postoperatively

ANS: A

The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. Although the client will need to sleep in a semi-Fowler’s position to assist in avoiding aspiration if vomiting does occur, this will not be as high a priority as knowing how to cut the wires.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

11. Which client is at greatest risk for development of obstructive sleep apnea?

a.            Woman who is 8 months pregnant

b.            Middle-aged man with gastroesophageal reflux disease

c.             Middle-aged woman who is 50 pounds overweight

d.            Older man with type 2 diabetes and a history of sinus infections

ANS: C

The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 584

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)