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CHAPTER 20 Caring for Clients With Upper Respiratory Disorders

3. The nurse is providing postoperative care for a client who has undergone tonsillectomy. In which position will the nurse place the head of the bed when the client is fully awake?

NEXT-GENERATION NCLEX-STYLE CLINICAL SCENARIO QUESTIONS Clinical Scenario:

Over the past 6 months, a young adult was seen in a clinic with repeated fevers of at least 38.5°C, enlarged and painful lymph nodes in the neck, white patches on the tonsils, and positive strep tests. The client is scheduled for a tonsillec tomy today. 1. A client diagnosed with tonsillitis is scheduled for a tonsillectomy today. What following signs and symptoms would the nurse expect to see? Select all that apply. a. Positive strep test b. Frequent sore throat

a. Flat with the head elevated on a pillow b. Slightly raised at a 15-degree angle c. Raised at a 45-degree angle d. Raised at a 90-degree sitting position

4. A client was seen in the emergency department with severe epistaxis. After the primary provider places a nasal packing, the bleeding is controlled. What should the nurse include as part of the discharge instructions? Select all that apply. a. Call the primary provider if bleeding persists or becomes worse. b. Continue taking baby aspirin as ordered. c. Do not blow the nose. d. Keep nasal packing in place until seen for follow up appointment. e. Swallow any oozing blood to avoid coughing. 5. The nurse is reviewing the record of a client who is being seen for possible laryngeal cancer. What initial complaint from the client does the nurse expect? a. The client has had difficulty swallowing hot liquids. b. The client has had enlarged lymph nodes in the neck. c. The client has had generalized discomfort in the neck. d. The client has had persistent hoarseness for the last month. 6. A nurse identified Ineffective Airway Clearance related to a malignant mass in the client’s airway. Which of the following interventions has the highest priority? a. Elevate the client’s head of the bed. b. Encourage the client to deep breathe and cough every 2 hours. c. Place a nasal cannula with 2 L of oxygen. d. Provide emergency tracheostomy equipment at the bedside.

c. Painful neck lymph nodes d. Fever of at least 38.5°C e. White patches on tonsils f. Enlarged neck lymph nodes

2. A client is scheduled to have a tonsillectomy. What are effective actions to relieve a client’s symptoms? Select all that apply. a. Antipyretics b. NSAIDs c. Decreased fluid intake d. Ice packs to the neck area

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