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 the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?
Correct Answer: C
Rationale: Major goals of intubation are to improve respirations and maintain a patent airway for gas exchange. Regular auscultation of the lung fields is essential in confirming that air is reaching the lung fields for gas exchange. All other options are important to provide assessment data.
Question 2 of 5
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?
Correct Answer: B
Rationale: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube.Bilateral breath sounds are an expected finding; the absence of bilateral breath sounds should be reported to the provider immediately.
Question 3 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 4 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 5 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.