N4 test Upper Respiratory Problems

Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking for Collaborative Care, 4th Edition
Chapter 29: Interventions for Clients with Noninfectious Upper Respiratory Problems

1. On a home visit to a client with diabetes mellitus, you find the client having an anterior nosebleed. What is your best first action?
A. Position the client in an upright position, leaning backward with the neck hyperextended.
B. Gently inspect the nares and inside of the nose with a nasal speculum.
C. Apply direct, lateral pressure to the sides of the nose for 5 minutes.
D. Administer humidified oxygen by mask at 2 L/minute.

2. The client with a nasal fracture is 4 hours postop after a rhinoplasty. During assessment, you observe the client swallowing approximately 10 times each minute. What is your best action?
A. Document return of the swallowing reflex.
B. Offer the client small sips of water or ice chips.
C. Examine the posterior pharynx with a penlight for bleeding.
D. Apply cold compresses or ice packs to the neck and jaw areas.

3. Clients with sleep apnea are at increased risk for which health problem?
A. Accidents as a result of excessive daytime sleepiness.
B. Infection as a result of apnea-induced immunodeficiency.
C. Aspiration pneumonia from lack of epiglottal movement during breathing.
D. Chronically decreased deep tendon reflexes as a result of cerebral hypoxia.

4. Which intervention should you use to assist with communication for the client who has disruption of speech and cannot read?
A. Send the client to receive speech therapy.
B. Teach the client to use a pictureboard.
C. Supply the client with a magic slate.
D. Teach the client to lip-read.

5. The client fell from a second-floor balcony and has a neck injury. Which function or assessment finding indicates to you that the client’s airway is currently adequate? The:
A. client is able to talk.
B. client is alert and oriented.
C. client’s chest muscles are firm.
D. client’s oxygen saturation is 97%.

6. The client is suspected of having cancer of the head and neck. Which personal data related by the client increases the risk for this type of cancer?
A. A 75-pack-year smoking history
B. Adult onset diabetes mellitus
C. Surgery for colorectal cancer 7 years ago
D. Worked as an operating room nurse for 30 years

7. What is the priority nursing diagnosis for the client going home following a total laryngectomy for head and neck cancer?
A. Risk for aspiration related to surgical procedure
B. Self-care deficit (dressing/grooming) related to fatigue
C. Deficient knowledge related to the risk for cancer recurrence with continued cigarette smoking
D. Altered nutrition: less than body requirements, related to disruption of the aerodigestive tract