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 had a tracheostomy two hours ago. The nurse assesses the client and finds the client's breathing is shallow, with a respiratory rate of 30 . The nurse notes increased mucus production around the tracheostomy and on the dressing. What is the priority nursing concern(s)? Select all that apply.
Correct Answer: A,D
Rationale: The client with a new tracheostomy tube has increased secretions, which may become dried and occlude or plug the airway, requiring frequent suctioning. Impaired gas exchange and airway clearance are priority nursing concerns. Infection, knowledge deficit, and altered body image are concerns, but not priorities.
Question 2 of 5
The nurse is an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factor(s) would the nurse be sure to include in the workshop? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Carcinogens, such as tobacco, alcobol, and industrial pollutants, are associated with laryngeal cancer. The age of the client is also a factor, with a higher incidence among those 65 years of age or older. Region of country lived in is notassociated with laryngeal cancer as a specific risk factor.
Question 3 of 5
The nurse is providing tracheostomy care for a client. Place the following steps in the order the nurse should perform them.
Correct Answer: C,A,B,D,E,G,F
Rationale: The nurse should position client in a supine or low Fowler position. Using a clean glove, the nurse should remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle. The nurse should then open the tracheostomy kit without contaminating the contents. The nurse should don sterile gloves, keeping the dominant hand sterile. Next, the nurse should pour hydrogen peroxide and normalsaline into respective containers. The nurse should then unlock the inner cannula by turning it counterclockwise, afterward removing it and placing it in hydrogen peroxide. The nurse should clean the inside and outside of the cannula with pipe cleaners. Next, the nurse should rinse the cleaned cannula with normal saline. The nurse should then tap the cannula and wipe the excess solution with sterile gauze. Next, the nurse should replace the inner cannula and turn it clockwise within the outer cannula. The nurseshould then clean around the stoma with an applicator moistened with normal saline.Next, the nurse should place a sterile dressing around the tracheostomy tube andchange the tracheostomy ties by placing the new ones on first and removing the soiled ones last. Finally, the nurse should tie the new ends securely, but not tightly, at theside of the neck. The nurse should perform hand hygiene before, during, and after the procedure.
Question 4 of 5
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
Correct Answer: D
Rationale: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following atracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.
Question 5 of 5
The nurse is caring for a client who is post-sinus surgery. When assessing the client, the nurse asks how many the nurse is holding up. Why does the nurse assess postoperative visual acuity?
Correct Answer: B
Rationale: A client who has undergone a sinus surgery faces a serious risk of damage to the optic nerve.
Therefore, the nurse assesses postoperative visual acuity by asking the client to identify the number of fingers displayed.
To assess possible hemorrhage, the nurse observes the client for repeated swallowing. The nurse assesses for pain over the involved sinuses and not a postoperative infection or an impaired drainage.