Ch. 26 - Upper Respiratory

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical exams in Sept. Which patients should receive the inactivated influenza vaccine. Select all. a. A 76 yr old nursing home resident. b. A 36 yr old female patient who is pregnant. c. A 42 yr old patient who has a 15 pack year smoking history d. A 30 year old patient who takes corticosteroids for rheumatoid arthritis. e. A 24 yr old patient who has allergies to penicillin and cephalosporins

A, B, D

The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session. Select all. a. Decongestants can be used to relive swelling b. Blowing the nose should be avoided to decrease the nosebleed risk c. Taking a hot shower will increase sinus drainage and decrease pain d. saline nasal spray can be made at home and used to wash out secretions e. you will be more comfortable if you keep head in an upright position

A, C, D, E

The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed. a. I must keep the stoma covered with an occlusive dressing at all times b. I can participate in most of my prior fitness activities except swimming. c. I should wear a medic alert bracelet that identifies me as a neck breather. d. I need to be sure that I have smoke and carbon monoxide detectors installed.

A. I must keep the stoma covered with an occlusive dressing at all times. rationale: An occlusive dressing will completely block the patients airway

The patient has decided to use the voice rehabilitation that offers the best speech quality even though it must be cleaned regularly. The nurse knows that this is what kind of voice rehabilitation a. Electromyography b. Intraoral electrolarynx c. Neck type electrolarynx d. Transesophageal puncture

Transesophageal puncture rationale: provides a fistula between the esophagus and trachea with a one way valved prosthesis to prevent aspiration from the esophagus to the trachea.

The nurse observes clear nasal drainage in a patient newly admitted with facial trauma with a nasal fracture. What is the nurses priority action. a. Test the drainage for the presence of glucose b. Suction the nose to maintain airway clearance. c. Document the findings and continue monitoring d. Apply a drip pad and reassure the patient this is normal.

a. test the drainage for the presence of glucose rationale: Clear nasal drainage suggests leakage of cerebrospinal fluid. Presence of glucose would indicate the presence of CSF

When initially teaching a patient the supraglottic swallow after a radical neck dissection, with which food or fluid should the nurse begin a. Cola b. applesauce c. french fries d. white grape juice

a Cola rationale: when learning the supraglottic swallow, it may be helpful to start with carbonated beverages because the effervescence provides clues about the liquids position.

A nurse obtains a health history from a patient who has a 35 pack year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most important for the nurse to ask a. How much alcohol do you drink in an average week b. Do you have a family history of head or neck cancer c. Have you had frequent streptococcal throat infections d. Do you use antihistamines for upper airway congestion

a. How much alcohol do you drink in an average week rationale: Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever.

Which statement by the patient indicates that the teaching has been effective for a patient scheduled for radiation therapy of the larynx. a. I will need to buy a water bottle to carry with me. b. I should not use any lotions on my neck and throat c. until the radiation is complete, I may have diarrhea d. Alcohol based mouthwashes will help clean oral ulcers.

a. I will need to buy a water bottle to carry with me. rationale: Xerostomia can be partially alleviated by drinking fluids at frequent intervals.

the nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated. a. Use a manometer to ensure cuff pressure is at an appropriate level. b. check the amount of cuff pressure ordered by the health care provider. c. Suction the patient first with a fenestrated inner cannula to clear secretions d. Insert the decannulation plug before the nonfenestrated inner cannula is removed.

a. Use a manometer to ensure cuff pressure is at an appropriate level. rationale: Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries.

Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first. a. A 23 yr old who is complaining of a sore throat and has a muffled voice b. A 34 yr old who has a scratchy throat and a positive rapid strep antigen test. c. A 55 yr old who is receiving radiation for throat cancer and has severe fatigue. d. A 72 yr old with a history of a total laryngectomy whose stoma is red and inflamed.

a. a 23 yr old who is complaining of a sore throat and has a muffled voice. rationale: patients clinical manifestation of a muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment.

After being hit by a baseball, a patient arrives in the ED with a possible nasal fracture. Which finding by the nurse is the most important to report to the HCP. a. Clear nasal drainage b. Complaint of nasal pain c. Bilateral nose swelling and bruising d. Inability to breathe through the nose.

a. clear nasal drainage rationale: Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid

The nurse is caring for a hospitalized patient who has nasal packing in place to treat a nosebleed. Which assessment finding will require the most immediate action by the nurse. a. The oxygen saturation is 89% b. The nose appears red and swollen c. The patients temp is 100.1 d. The patient complains of level 8 pain

a. the oxygen saturation is 89%

The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident? a. hypersensitivity to eggs b. Age older that 80 years c. history of upper respiratory infections d. COPD

a. hypersensitivity to eggs. rationale: hypersensitivity to eggs precludes vaccination because the vaccine is produced in eggs

Which action should the nurse take first when a patient develops a nose bleed. a. Pinch the lower portion of the nose for 10 minutes b. Pack the affected nare tightly with an epistaxis balloon c. Obtain silver nitrate that will be needed for cauterization d. Apply ice compress over the patients nose and cheeks.

a. pinch the lower portion of the nose for 10 mins

Which nursing action could the RN working in a skilled care hospital delegate to an experienced LPN caring for a patient with a permanent tracheostomy a. Assess the patients risk for aspiration b. Suction the tracheostomy when needed. c. Teach the patient about self care of the tracheostomy d. Determine the need for replacement of the tracheostomy tube.

b. Suction the tracheostomy when needed.

Following a laryngectomy a patient coughs violently during suctioning and dislodges the trach tube. Which action should the nurse take first a. Cover stoma with sterile guaze and ventilate through stoma b. Attempt to reinsert the tracheostomy tube with the obturator in place. c. Assess the patients oxygen saturation and notify the HCP d. Ventilate the patient with a manual bag and face mask until the HCP arrives.

b. attempt to reinsert the tracheostomy tube with the obturator in place. rationale: first action should be to attempt to reinsert the tracheostomy tube to maintain the patients airway

The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the HCP a. Fever of 100.4 F b. Diffuse crackles in the lungs c. Sore throat and frequent cough d. Myalgia and persistent headache.

b. diffuse crackles in the lungs rationale: crackles indicate the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment.

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when the tracheostomy tube is expelled by coughing. What is the priority action by the nurse? a. Suction the tracheostomy opening b. Maintain the airway with a sterile hemostat c. Use an Ambu bag and mask to ventilate the patient. d. Insert the tracheostomy tube obturator into the stoma.

b. maintain the airway with a sterile hemostat

A patient has a tracheostomy tube after reconstructive surgery for invasive head and neck cancer. What is most important for the nurse to assess before performing tracheostomy care? a. level of consciousness b. quality of breath sounds c. Presence of the gag reflex d. Tracheostomy cuff pressure

b. quality of breath sounds. rationale: Before performing tracheostomy care, the nurse will auscultate lung sounds to determine the presence of secretions.

Which task can the RN delegate to UAP in the care of a stable patient who has a tracheostomy. a. Assessing the need for suctioning b. Suctioning the patients oropharynx c. Assessing the patient swallowing ability d. Maintaining appropriate cuff inflation pressure

b. suctioning the patients oropharynx rationale: they must be trained, but the UAP may suction the patients oropharynx.

When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temp of 101.6, and yellow patches on the tonsils. Which action will the nurse anticipate taking? a. teach the patient about the use of expectorants b. Use a swab to obtain a sample for a rapid strep antigen test c. Discuss the need to rinse the mouth out after using inhalers. d. Teach the patient to avoid use of nonsteroidal antiinflammatory drugs

b. use a swab to obtain a sample for a rapid strep antigen test.

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist. a. leave the tracheostomy inner cannula inserted at all times. b. place the decannulation cap in the tube before cuff deflation c. Assess the ability to swallow before using the fenestrated tube. d. Inflate the tracheostomy cuff during use of the fenestrated tube

c. Assess the ability to swallow before using the fenestrated tube. rationale: Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube.

A patient with a history of tonsillitis reports difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse. a. Bilateral erythema of especially large tonils b. Temp. of 102.2, diaphoresis, and chills. c. Contraction of neck muscles during inspiration d. B-hemolytic streptococcus in the throat culture.

c. Contraction of neck muscles during inspiration rationale: indicates that the patient is using accessory muscles for breathing and is in serious respiratory distress.

The nurse discusses management of upper respiratory infections with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed. a. I can take acetaminophen (Tylenol) to treat my discomfort. b. I will drink lots of juices and other fluids to stay well hydrated. c. I can use my nasal decongestant spray until the congestion is all gone d. I will watch for changes in nasal secretions or the sputum that I cough up.

c. I can use my nasal decongestant spray until the congestion is all gone rationale: The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective.

A nurse who is caring for a patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take a. Encourage increased incentive spirometer use b. encourage the patient to increase oral fluid intake c. Put on sterile gloves and use a sterile catheter to suction d. Pre-oxygenate the patient for 3 mins before suctioning

c. Put on sterile gloves and use a sterile catheter to suction rationale: This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary.

The patient has been diagnosed with head and neck cancer. Along with the treatment for cancer, what other treatment should the nurse expect to teach the patient about. a. Nasal packig b. epistaxis balloon c. Gastrostomy tube d. Peripheral skin care

c. gastrostomy tube rationale: 50% of patients with head and neck cancer are malnourished before treatment begins, many patients need enteral feeding via a gastrostomy tube because the effects of treatment make it difficult to take in enough nutrients orally, whether surgery, chemotherapy, or radiation used.

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that this identified problem is resolving. a. the patient lets the spouse provide tracheostomy care b. the patient allows the nurse to suction the tracheostomy c. the patient asks how to clean the tracheostomy stoma and tube d. the patient uses a communication board to request "no visitors"

c. the patient asks how to clean the tracheostomy stoma and tube. rationale: independently caring for the laryngectomy tube indicates that the patient has regained control of personal care.

The nurse teaches a patient about discharge instructions after rhinoplasty. Which statement, if made by the patient, indicates that teaching was successful a. I can take 800 mg ibuprofin for pain control b. i will safely remove and reapply nasal packing daily c. My nose will look normal after 24 hours when the swelling goes away d. I will keep my head elevated for 48 hrs to minimize swelling and pain.

d. I will keep my head elevated for 48 hrs to minimize swelling and pain. rationale: Maintaining the head in an elevated position will decrease the amount of nasal swelling. NSAIDs, such as ibuprofen, increase the risk for postoperative bleeding and should not be used postoperatively.

The nurse teaches a patient about the use of budesonide intranasal spray for seasonal allergic rhinitis. The nurse determines that medication teaching is successful if the patient makes which statement? a. My liver function will be checked with blood tests every 2 to 3 months. b. The medication will decrease the congestion within 3 to 5 minutes after use. c. I may develop a serious infection because the medication reduces my immunity d. I will use the medication every day of the season whether I have symptoms or not

d. I will use the medication every day of the season whether I have symptoms or not.

The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan a. hand washing is the primary way to prevent spreading the condition to others. b. Use of oral antihistamines for 2 weeks before the allergy season may prevent reactions c. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. d. Identification and avoidance of environmental triggers are the best way to avoid symptoms.

d. Identification and avoidance of environmental triggers are the best way to avoid symptoms. rationale: The most important intervention is to assist the patient in identifying and avoiding potential allergens.

A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being "stuck up my nose" and with foul smelling nasal drainage from the right nare. Which action should the nurse take first. a. Notify the clinic HCP b. Obtain aerobic culture specimens of the drainage c. Ask the patient about how the cotton got into the nose d. Have the patient occlude the left nare and blow the nose

d. have the patient occlude the left nare and blow nose. rationale: because the highest priority action is to remove the foreign object from the nare, the nurses first action should be to assist the patient to remove the object.

The nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery, what is the priority nursing action a. Monitor for bleeding b. Maintain adequate IV fluid intake c. Suction tracheostomy every eight hours d. Keep the patient in semi fowlers position

d. keep the patient in semi fowlers position. rationale: maintain the airway and ensure adequate oxygenation

A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement. a. Apply an external splint to the nose b. Insert plastic nasal implant surgically c. Humidify the air for mouth breathing d. Maintain surgical packing in the nose

d. maintain surgical packing in the nose rationale: to prevent the formation of a septal hematoma and potential infections resulting from a septal hematoma

The patient seeks relief from the symptoms of an upper respiratory infection (URI) lasting for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis? a. Coughing b. Fever, chills c. Dust allergy d. Maxillary pain

d. maxillary pain rationale: The nurse should assess the patient for sinus pain or pressure as a clinical indicator of acute sinusitis.

A patient is admitted for joint replacement surgery and has a permanent tracheostomy. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. suction the tracheostomy b. check stoma site for skin breakdown c. Complete tracheostomy care using sterile technique d. Provide oral care with a toothbrush and tonsil suction tube

d. provide oral care with a toothbrush and tonsil suction tube

The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care a. Avoid giving the patient warm liquids to drink b. Assess patient for allergies to penicillin antibiotics c. Teach the patient about the need to sleep in a warm, dry environment d. Teach the patient to "swish and swallow" prescribed oral nystatin (Mycostatin)

d. teach the patient to swish and swallow prescribed oral nystatin. rationale: oral or pharyngeal fungal infections are treated with nystatin solution

A patient is scheduled for a total paryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery". What is the best response by the nurse. a. You will breathe through a permanent opening in your neck, but you will not be able to communicate orally. b. You wont be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed. c. You wont be able to speak as you use to, but there are artificial voice devices that will give you the ability to speak normally d. You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration

d. you will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration. rationale: Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication