Chapter 18: Management of patients with upper respiratory tract disorder

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:

"I should become involved in a weight loss program."

The nurse is caring for a client who has had a laryngectomy to treat laryngeal cancer. Which instruction should the nurse include in the teaching about the neck stoma?

"Use humidification of the environment to prevent crusting around the stoma."

A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:

A permanent tracheal stoma would be necessary.

The nurse is assessing a patient who smokes 2 packs of cigarettes per day and has a strong family history of cancer. What early sign of cancer of the larynx does the nurse look for in this patient?

Affected voice sounds

The nurse should advise the patient who has nasal packing for epistaxis that the packing can be left in place:

Anywhere from 2 to 6 days.

The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Auscultate lung sounds

A 13-year-old soccer player presents to the emergency room with a fractured nose. The patient's mother is given which of the following post-discharge instructions? Select all that apply.

Check for any unusual changes in breathing during the first 48 hours. Observe for any clear drainage from either nostril. Elevate the head of the bed for sleeping during the first week. Restrict from sports activities for 6 weeks.

The nurse knows that there are three types of chronic pharyngitis. Which of the following is characterized by numerous swollen lymph follicles on the pharyngeal wall?

Chronic granular

A client seeks care for hoarseness that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question?

Do you smoke cigarettes, cigars, or a pipe?

Late symptoms of laryngeal cancer include which of the following. Select all that apply.

Dysphagia Dyspnea Persistent hoarseness

A patient prescribed a medication for hypertension started taking it 3 days ago and arrives in the emergency department with an edematous face and tongue and having a difficult time speaking. What medication is the nurse aware of that may produce this type of side effect?

Enalapril (Vasotec)

A nurse is teaching a client with recurrent rhinosinusitis. What medication will the nurse instruct the client to take at the first sign of symptoms?

Guaifenesin

Select the nursing diagnosis that would warrant immediate health care provider notification.

Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation

A patient comes to the clinic with a cold and wants something to help relieve the symptoms. What should the nurse include in educating the patient about the uncomplicated common cold? (Select all that apply.)

Inform the patient about symptoms of secondary infection Suggest that the patient take adequate fluids and get plenty of rest Inform the patient that the virus is contagious for 2 days before symptoms appear and during the first part of the symptomatic phase

The nurse makes the observations shown in the accompanying notes about a client who will be discharged following a laryngectomy. The nurse makes a referral to the home health nurse for client reteaching based on which observation?

Initial washing of hands after cleaning inner cannula.

The nurse is instructing a client who is scheduled for a laryngectomy about methods of laryngeal speech. Which best describes tracheoesophageal puncture (TEP)?

It requires the insertion of a prosthesis into the trachea.

The nurse is caring for a client receiving radiation therapy for laryngeal cancer. Which is a late complication of radiation therapy?

Laryngeal necrosis

patient diagnosed 2 weeks ago with acute pharyngitis comes to the clinic stating that the sore throat got better for a couple of days and is now back along with an earache. What complications should the nurse be aware of related to acute pharyngitis? (Select all that apply.)

Mastoiditis Otitis media Peritonsillar abscess Explanation: Uncomplicated viral infections usually subside promptly, within 3 to 10 days after onset. However, pharyngitis caused by more virulent bacteria, such as GAS, is a more severe illness. If left untreated, the complications can be severe and life threatening. Complications include rhinosinusitis, otitis media, peritonsillar abscess, mastoiditis, and cervical adenitis. In rare cases, the infection may lead to bacteremia, pneumonia, meningitis, rheumatic fever, and nephritis.

The nurse is assessing a client for obstructive sleep apnea (OSA). Which are signs and symptoms of OSA? Select all that apply

Polycythemia Loud snoring Insomnia

A client presents to the ED with a suspected allergic reaction. The client is experiencing laryngeal edema, which is causing obstruction, and is demonstrating retractions in the neck during inspiration. Which is the nurse's priority intervention?

Prepare to administer subcutaneous epinephrine and corticosteroids

Which of the following interventions would be helpful for a client reporting nasal congestion, sneezing, sore throat, and muscle aches? Select all that apply

Provide warm salt-water gargles. Administer oral ibuprofen. Teach the client about handwashing. Recommend guaifenesin.

A client is experiencing acute viral rhinosinusitis. The nurse is providing instructions about self-care activities and includes information about

Saline lavages to the nares

Which diagnostic test is used to confirm the diagnosis of maxillary and frontal sinusitis?

Sinus aspirates

The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?

Sudden restlessness

When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?

Test the nasal drainage for glucose.

The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, "Elevate the head of the bed 45 degrees." This assists in meeting which nursing goal?

The client will have decreased edema.

Once the patient has been cleared for oral feedings, post laryngectomy, the nurse knows to prepare

Thick liquids that are easy to swallow.

The nurse in the ICU is caring for a client with a nasotracheal tube. Because of the tube placement, the nurse understands that the client is at risk for developing

a sinus infection

When a client has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the client very carefully because of the high risk for

carotid artery hemorrhage.

Another term for clergyman's sore throat is

chronic granular pharyngitis

The nurse is caring for a client diagnosed with rhinosinusitis. The physician has ordered the client to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the client that a common side effect of this medication is

epistaxis

A client is postoperative immediately following a total laryngectomy. The client's respirations are 32 breaths/minute, shallow, and noisy. The tracheostomy pad is moist with mucus. Pulse oximetry is 88%. The client's eyes are wide open, and the client appears apprehensive. What is a priority nursing concern?

ineffective airway clearance

As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that:

laryngeal cancer is one of the most preventable types of cancer.

A patient comes to the clinic complaining of a possible upper respiratory infection. What should the nurse inspect that would indicate that an upper respiratory infection may be present?

nasal mucosa

The nurse is caring for a client following a tonsillectomy and adenoidectomy. Two hours after the procedure, the client begins to vomit large amounts of dark blood at frequent intervals and is tachycardic and febrile. After notifying the surgeon, the nurse

obtains a light, mirror, gauze, and curved hemostats.

Bleeding from the drains at the surgical site or with tracheal suctioning may signal the occurrence of hemorrhage. Which of the following is a clinical manifestations associated with hemorrhage?

rapid and deep respirations

A client seeks medical attention for a hoarseness that has lasted for more than 2 weeks. Which additional finding indicates to the nurse that the client may need to be evaluated for cancer of the larynx?

sore throat

A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by

telling the client to sit upright with the head tilted forward

The nurse advises a patient who sustained a fractured nose during an automobile accident that surgery will be necessary. Due to significant facial edema, surgery would be scheduled:

within 1 week