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
The nurse in the walk-in clinic obtains a history of an upper respiratory infection with a red, sore throat. The client has been febrile for 3 days. Which nursing assessment should be stressed?
Correct Answer: B
Rationale: A pharyngitis occurs from inflammation of the throat, typically from a virus or bacteria. The most serious bacteria are the group A streptococci, commonly referred to as strep throat. Strep throat can have serious cardiac and renal complications,including sepsis. Assessing voiding can be an indication of renal status. Lung fields, joint pain, and mentation are completed in the head-to-toe assessment.
Question 2 of 5
The nurse is providing suggestions to a client diagnosed with the effects of coryza. Which home remedy is appropriate when combined with medical treatment for pharyngitis?
Correct Answer: D
Rationale: A salt water or saline gargle combines moisture from the water with sodium from the salt to aid in discomfort. Humidification and ice chips are also acceptable but just aids in soothing moisture to the air aiding in discomfort. A lavender scent isrelaxing but is not specifically a treatment appropriate to the condition described.
Question 3 of 5
The nurse is receiving the post-tonsillectomy and post-adenoidectomy client in the postanesthesia care unit (PACU). The nurse aide is assisting the client from the stretcher to the bed. The client remains drowsy from anesthesia. In which position would the nurse instruct the nurse aide to place the client?
Correct Answer: A
Rationale: Upon receiving the client in the PACU, the client is drowsy and not fully conscious. A standard of care to prevent aspiration is to place the client lying on either side with an emesis basin to catch drainage. Laying the client is a supine position,semi-Fowler's position, or high-Fowler's position does not provide an easy exit for secretions as the client is recovering from the anesthesia.
Question 4 of 5
The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, 'Elevate the head of the bed 45 degrees.' This assists in meeting which nursing goal?
Correct Answer: C
Rationale: Elevating the head of the bed 45 degrees when the client is fully awake decreases surgical edema and increases lung expansion. At this point in the recovery, elevating the head of the bed will not decrease the surgical pain as pain medication will be needed. Elevating the head of the bed will not affect mentation nor increase theblood supply.
Question 5 of 5
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?
Correct Answer: C
Rationale: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity.