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 respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?
Correct Answer: B
Rationale: A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device.
Question 2 of 5
The nurse is caring for a client with an upper respiratory disorder. The client states they have a hacky, nonproductive cough, which wakens them during the night. Which over-the-counter medication would the nurse suggest to diminish the cough during the night?
Correct Answer: B
Rationale: Dextromethorphan acts on the central nervous system to raise the cough threshold and dampen the cough reflex. Diphenhydramine is an antihistamine that relieves symptoms associated with allergies. Pseudoephedrine relieves nasalcongestion associated with sinusitis, colds, and allergies. Fluticasone reduces tissue edema.
Question 3 of 5
A client recently diagnosed with laryngeal cancer and awaiting a laryngectomy was encouraged to attend a support group prior to surgery. The client asked the nurse about the name of the laryngeal speech method where the client speaks with theassistance of a surgically implanted device. The nurse is correct to provide teaching on which method?
Correct Answer: C
Rationale: A tracheoesophageal puncture is the method where a client speaks with the assistance of a surgically implanted valve that diverts air through the esophagus through a surgical opening in the posterior wall of the trachea with the assistance of a voice prosthesis. Esophageal speech occurs from swallowing air and forming words with the lips. An artificial larynx is a throat vibrator or an apparatus that projectssound into the oral cavity. There is no available electronic voice box.
Question 4 of 5
The nurse is mentoring a new graduate nurse and the two are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. Which complication(s) would the nurse identify for the new nurse? Select all that apply.
Correct Answer: B,C,D
Rationale: The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall.
Question 5 of 5
The nurse is providing discharge instructions to a client diagnosed with postoperative tonsillectomy and adenoidectomy. Which discharge instruction(s) would the nurse include? Select all that apply.
Correct Answer: B,C,D,E
Rationale: A client may be at risk for postoperative bleeding for several days following the surgical procedure as the scab may be removed from the surgical site early causing the bleeding. Clients should avoid carbonated beverages and citrus fluids or foods because these agents are caustic to the suture line. The client should gradually increase fluids from thin liquids to thick liquids then soft foods through the recovery process. Applying an ice collar and gargling with saline decreases swelling and aids in preventing infection. Pain medication would be appropriate throughout the day, not just at night.