Upper Respiratory Disorders
A college student presents to the health clinical with signs and symptoms of viral rhinitis (common cold). The patient states, “I’ve felt terrible all week; what can I do to feel better?” Which of the following is the best response the nurse can give?
A. “Antibiotics will be prescribed, which will make you feel better.”
B. “Have you tried a topic nasal decongestant; they work well.”
C. “You should rest, increase your fluids, and take Ibuprofen.”
D. “Your symptoms should go away soon, just try to get some rest.”
C. “You should rest, increase your fluids, and take Ibuprofen.”
Management of viral rhinitis consists of symptomatic therapy that includes adequate fluid intake, rest, prevention of chilling, and use of expectorants as needed. Warm saltwater gargles soothe the sore throat, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, relieve aches and pains. Antibiotics are not prescribed because they do not affect the virus causing the patient’s signs and symptoms. Topical nasal decongestants should be used with caution. The symptoms of viral rhinitis may last from 1 to 2 weeks.
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched, musical, squeaking sounds. The nurse should document this as which of the following adventitious lung sounds?
A. Crackles
B. Rhonchi
C. Stridor
D. Wheezes
D. Wheezes
Wheezes are continuous, high-pitched squeaking or whistling sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. It is often possible to hear wheezes without a stethoscope.
During a community health fair, a nurse is teaching a group of seniors about promoting health and preventing infection. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections?
A. Receive vaccinations
B. Exercise daily
C. Drink six glasses of water daily
D. Take all prescribed medications
A. Receive vaccinations
Identifying clients who are at risk for pneumonia provides a means to practice preventive nursing care. The nurse encourages clients at risk of pneumococcal and influenza infections to receive vaccinations against these infections.
A nurse is collecting data from a client who is 2 days postoperative. The nurse auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?
A. Atelectasis
B. Rales
C. Rhonchi
D. Pneumothorax
A. Atelectasis
Atelectasis is incomplete alveolar expansion or collapse. Breath sounds are absent over areas of alveolar collapse.
A nurse is collecting data from a client who has respiratory insufficiency. Which of the following findings should the nurse identify as an early sign of inadequate oxygenation?
A. Diaphoresis
B. Retractions
C. Cyanosis
D. Restlessness
D. Restlessness
Early signs of inadequate oxygenation include unexplained apprehension, restlessness, irritability, tachypnea, tachycardia, dyspnea on exertion, and mild hypertension. Retractions of accessory muscles of respiration is a late manifestation of inadequate oxygenation. diaphoresis & cyanosis are also LATE signs.
You are caring for a patient in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The patient has a 25-year history of smoking. You perform an assessment and ask the patient about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer?
A. Hoarseness
B. Dyspnea
C. Dysphagia
D. Alopecia
A. Hoarseness
A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?
A. Restrict the client’s fluid intake to less than 1 L/day.
B. Encourage the client to use the upper chest for respiration.
C. Plan to have the client lay down for 1 hr after meals.
D. Instruct the client to use pursed-lip breathing.
D. Instruct the client to use pursed-lip breathing.
The nurse should include in the interventions for the client to use pursed-lip breathing, which lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation. This reduces airway resistance and decreases trapped air for clients who have COPD.
A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin the client’s respiratory secretions?
A. Encourage the client to ambulate more often.
B. Encourage coughing and deep breathing.
C. Encourage the client to drink more fluids.
D. Encourage regular use of the incentive spirometer.
C. Encourage the client to drink more fluids.
Fluids help liquefy and thin pulmonary secretions, which facilitates expectoration to clear the airways. The client should drink 1,500 to 2,500 mL/day to keep secretions thin.
A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus?
A. Tense and relax muscles in the lower extremities.
B. Wear tight-fitting clothing.
C. Limit fluid intake to <1L/day.
D. Begin estrogen replacement.
A. Tense and relax muscles in the lower extremities.
Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism.
A nurse is assisting with the care of a client who has a newly inserted chest tube. Which of the following actions should the nurse take?
A. Clamp the tube when the client is ambulating.
B. Keep the collection device below the client’s chest level.
C. Loop the client’s tubes carefully to prevent kinking.
D. Place the client flat to avoid leaks in the tubing.
B. Keep the collection device below the client’s chest level.
Which medication is the treatment of choice for bacterial pharyngitis?
A. Robitussin DM
B. Tylenol
C. Penicillin
D. Tylenol with codeine
C. Penicillin
The treatment of choice for bacterial pharyngitis is penicillin. Robitussin DM may be used as an antitussive. For severe sore throats aspirin or Tylenol, or Tylenol with codeine, may be given.
When providing discharge teaching to a patient who is newly diagnosed with asthma, which of these points should the healthcare provider emphasize?
a. "eliminate or reduce exposure to known asthma triggers"
b. "take your montelukast in the morning before breakfast"
c. "tilt your head forward when you use your inhaler"
d. "when you feel an attack is imminent, use your inhaled corticosteroid"
a. "eliminate or reduce exposure to known asthma triggers"
A 44-year-old homeless man presented to the emergency department with hemoptysis. The patient was diagnosed with tuberculosis (TB) after diagnostic testing and has just begun treatment with INH, pyrazinamide, and rifampin (Rifater). When providing patient education, what should the nurse emphasize?
A. The rationale and technique for using incentive spirometry
B. The correct use of a metered-dose inhaler (MDI) for bronchodilators
C. The need to maintain good nutrition and adequate hydration
D. The importance of adhering to the prescribed treatment regimen
D. The importance of adhering to the prescribed treatment regimen
Successful treatment of TB is wholly dependent on the patient's conscientious adherence to treatment. Patient education relating to this fact is a priority over MDIs, incentive spirometry, or nutrition, although each may be necessary.
A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula. The client tells the nurse she has been having difficulty breathing. Which of the following actions is the nurse's priority at this time?
A. Instruct the client to use a pursed-lip breathing technique.
B. Evaluate the client's respiratory status.
C. Increase the oxygen flow to 3L/min.
D. Have the client cough and expectorate secretions.
B. Evaluate the client's respiratory status.
The first action the nurse should take when using the nursing process is to collect data from the client. The nurse should immediately evaluate the client's respiratory status before determining the appropriate interventions.
Constant bubbling in the water seal of a chest drainage system indicates:
A. Air leak
B. Tidaling
C. Nothing, this is expected
D. Increased drainage
A. Air leak
The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal, which show effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.
During the winter, increased instances of acute bronchitis cause a backlog of physician appointments that spill over into ED visits. What is the most common cause of acute bronchitis infections?
A. Viral infections
B. Bacterial infections
C. Chemical irritation
D. Bronchial asthma
A. Viral infections
Viral infections most commonly give rise to acute bronchitis.
A nurse is caring for a client with COPD whose arterial blood gas results show the following results: pH: 7.2, PaCO2: 50, HCO3: 24. The nurse should identify the client is experiencing which of the following acid-base conditions?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
C. Respiratory acidosis
A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy?
A. Cracks in oral mucous membranes
B. Poor skin turgor
C. Tachycardia
D. Excessive pulmonary secretions
A. Cracks in oral mucous membranes
Oxygen therapy, especially when long-term or without sufficient humidification, is extremely drying to the nasal and oral mucosa and can cause cracks. Excessive pulmonary secretions are probably due to pneumonia, not oxygen therapy. A wide variety of clinical conditions can cause tachycardia, and it generally increases the body’s demand for oxygen. However, it is not an adverse effect of oxygen therapy. Poor skin turgor results from dehydration, which is not a typical adverse effect of oxygen therapy.
A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients?
A. Passive range of motion exercises for the upper and lower extremities
B. Early ambulation and the use of compression stockings
C. Incentive spirometry and deep breathing and coughing exercises
D. Maintenance of SpO2 levels ≥90% using supplementary oxygen
B. Early ambulation and the use of compression stockings
For patients at risk for PE, the most effective approach for prevention is to prevent deep venous thrombosis (DVT). Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression or intermittent pneumatic compression stockings are general preventive measures. Range of motion exercises, supplementary oxygen, incentive spirometry, and deep breathing exercises are not measures that directly reduce a patient's risk of DVT and consequent PE.
Interpret the following ABGs. Include if it is uncompensated or partially compensated.
pH: 7.48
CO2: 22
HCO3: 21
Respiratory alkalosis, partially compensated
Diagnosis and treatment of strep throat is important to avoid which serious complications? Select all that apply.
A. endocarditis
B. rheumatic fever
C. glomerulonephritis
D. laryngeal cancer
E. oral candidiasis
A, B, C.
Strep throat can lead to dangerous cardiac complications (endocarditis and rheumatic fever) and harmful renal complications (glomerulonephritis).
The patient asks the nurse why the physician ordered beclomethasone (Beclovent) for his COPD. Which statement by the nurse is most appropriate?
a. "Beclovent prevents airway dilation."
b. "Beclovent decreases inflammation, and makes it easier to breathe."
c. "Beclovent suppresses the immune response."
d. "Beclovent decreases responsiveness to medications that dilate the airway."
b. "Beclovent decreases inflammation, and makes it easier to breathe."
Rationale: Beclovent is an inhaled corticosteroid that is thought to decrease inflammation and dilate the airway. Preventing airway dilation is undesirable for this patient, and the exact opposite action of Beclovent. The exact mechanism of action is unknown. Becolvent, like any other corticosteroid, does suppress the immune response, but this is not the rationale for administration of the medication. Inhaled corticosteroids are thought to increase responsiveness of bronchial smooth muscle to beta-agonist drugs.
A client with pneumonia has developed pleurisy. Which of the nurse's assessment findings would best corroborate this diagnosis?
A. The client is experiencing painless hemoptysis.
B. The client's arterial blood gases (ABGs) are normal, but the client demonstrates increased work of breathing.
C. The client's oxygen saturation level is below 88%, but the client denies shortness of breath.
D. The client's pain intensifies when the client coughs or takes a deep breath.
D. The client's pain intensifies when the client coughs or takes a deep breath.
The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. The client's ABGs would most likely be abnormal and shortness of breath would be expected.
What are the conditions that make up Virchow’s triad? Select all that apply.
A. Hypercoagulaility
B. Disruption of the vessel lining
C. Hypocoagulability
D. Edema
E. Venostasis
A, B, E.
Three conditions, referred to as Virchow’s triad, predispose a person to clot formation: venostasis, disruption of the vessel lining, and hypercoagulability. Edema plays no part in Virchow’s triad.
A nurse is admitting a client who is having an exacerbation of asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following prescribed medications?
A. Propranolol
B. Aminophylline
C. Montelukast
D. Prednisone
A. Propranolol
The nurse should clarify a prescription for propranolol in a client who has asthma. Medications that block beta-2 receptors, such as propranolol, are contraindicated in clients who have asthma because they result in bronchoconstriction of the airways.