Chapter 31: Care of Patients with Noninfectious Upper Respiratory Problems

Chapter 31: Care of Patients with Noninfectious Upper Respiratory Problems

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. A high school athlete has suffered a nasal fracture. What is the priority action of the nurse caring for the client?

a.	Assess for pain.
b.	Pack the nares to prevent blood loss.
c.	Assess for bone displacement.
d.	Assess for airway patency.

 

 

ANS:  D

A patent airway is the priority. The nurse first should make sure that the airway is patent, then should determine whether the client is in pain, and whether bone displacement or blood loss has occurred.

 

DIF:    Cognitive Level: Application/Applying or higher

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

MSC:  Integrated Process: Nursing Process (Implementation)

 

2. After facial trauma, a client has a nasal fracture and is reporting constant nasal drainage, a headache, and difficulty with vision. What is the nurse’s first action?

a.	Collect the nasal drainage on a piece of filter paper.
b.	Send the client for a facial x-ray.
c.	Perform a vision test.
d.	Palpate all facial areas for crepitus.

 

 

ANS:  A

The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebral spinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the client’s risk for infection.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Implementation)

 

3. What is the nurse’s most important action after a client’s gag reflex has returned post rhinoplasty?

a.	Teach the client to change position every 2 hours.
b.	Tell the client to put heating pads on the face.
c.	Instruct the client to lay flat.
d.	Have the client drink at least 2500 mL/day.

 

 

ANS:  D

Once the gag reflex has returned, the client should drink at least 2 1/2 liters per day. The client should not change position frequently; the best position is semi-Fowler’s. Ice rather than heat should be applied. Lying flat is not recommended.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Implementation)

 

4. A client reports waking up feeling very tired, even after 8 hours of good sleep. What is the nurse’s best action?

a.	Ask for an order for sleep medication.
b.	Tell the client not to drink beverages with caffeine.
c.	Tell the client not to lie flat at night.
d.	Ask the client whether he or she has ever been evaluated for sleep apnea.

 

 

ANS:  D

Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Assessment)