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 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.
Question 2 of 5
The nurse is performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would the nurse ask the client about the use of herbal supplements?
Correct Answer: C
Rationale: The nurse must find out the bleeding tendencies of clients scheduled for tonsillectomy and adenoidectomy.
Therefore, the nurse asks the clients about any recent use of herbal supplements. The nurse must ask about the use of thesesupplements because they may prolong bleeding. A client may experience anorexia because of a diminished sense of taste and smell following a laryngectomy. Similarly, excess zinc impairs the immune system and lowers the levels of high-density lipoproteins. These symptoms are not caused by herbal supplements.
Question 3 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 4 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 5 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.