ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 20 : Caring for Clients With Upper Respiratory Disorders Questions
Question 1 of 5
A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis?
Correct Answer: C
Rationale: The severity and location of bleeding determine the treatment of a client with epistaxis.
To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.
Question 2 of 5
The nurse is presenting about upper respiratory infections at an educational event for a local community group. What should the nurse be sure to include regarding cold tablets containing first-generation antihistamines?
Correct Answer: C
Rationale: The nurse should include information about the side effect of urinary hesitancy with first-generation antihistamines. This class of drugs can also cause drowsiness and dry mouth. Aspirin prolongs bleeding.
Question 3 of 5
The nurse is caring for a client who is status post nasal polypectomy. What would the nurse instruct this client to report?
Correct Answer: A
Rationale: The nurse inspects the nasal packing and dressings frequently for bleeding and asks the client to report excessive swallowing, which can indicate bleeding. Nasal stuffiness and diarrhea do not indicate postoperative bleeding. Coughing can loosen or expel scabs on the surgical wounds.
Question 4 of 5
The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently?
Correct Answer: A
Rationale: The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation. The priorities are always airway, breathing, and then circulation.
Question 5 of 5
The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?
Correct Answer: A
Rationale: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opensthe nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best.