chapter 20

A client visits the physician's office concerned about possible sleep apnea. The client states he lives alone and fears that he will not awaken from sleep. The client states that he has many symptoms which may indicate sleep apnea. Which symptom, stated by the client, is not a symptom of sleep apnea?

"I have pressure in the middle of my chest at night."

The nurse is caring for the client who presents to the clinic with hoarseness for 2 months. Further testing diagnoses laryngeal cancer with the treatment plan of a radical neck dissection. When reinforcing information provided by the physician, which nursing instruction is most correct?

The physician removes lymph nodes, muscles and tissue.

You are presenting about upper respiratory infections at an educational event for a local community group. What should you be sure to include regarding cold tablets containing antihistamines?

They decrease discomfort temporarily.

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

A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy?

tell my wife about it, i do not want to touch it

You are caring for a client who is 42 years old and status post adenoidectomy. You find the client in respiratory distress when you enter his room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect?

edema in the upper airway

. The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?

face mask

You are caring for a client who is status post nasal polypectomy. What would you instruct this client to report?

Excessive swallowing

The nurse is caring for a client with a new tracheostomy. Which of the following nursing diagnoses are priorities? Select all that apply.

Ineffective Airway Clearance related to increased secretions Impaired Gas Exchange related to shallow breathing and anxiousness

The nurse is caring for a client diagnosed with coryza possibly from the rhinovirus. Vital signs are temperature: 101.2° F, pulse: 72 beats/minute, respirations: 28 breaths/minute, blood pressure: 112/70 mm Hg. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are course in the bases. Which afternoon assessment finding suggests the advancement to an infectious process?

temperature rise

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°." This assists in meeting which nursing goal?

the client will have decreased edema

The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose?

transillumination of the sinus

The nurse in the walk-in clinic obtains a history of an upper respiratory infection with a red, sore throat. The client has been febrile for 3 days. Which nursing assessment should be stressed?

voiding

You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

Noisy breathing

The emergency department nurse is assessing a client following a motor vehicle accident. The nurse notes facial deformities with swelling and bleeding and a clear drainage coming from the nares. Which diagnostic test is completed to determine if the clear drainage is cerebrospinal fluid?

a dextrostix

You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently?

airway patency

The nurse is caring for a client experiencing laryngeal trauma. Upon assessment, swelling and bruising is noted to the neck. Which breath sound is anticipated?

audible stridor without using stethosocpe

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

develop an alternate method of communication

A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first?

place a dilator in the stoma to maintain an opening

. The nurse is caring for a geriatric client brought to the emergency department after being found by her children feeling poorly with an elevated temperature. Laboratory tests confirm influenza type A, a respiratory virus. Which medical treatment would the nurse anticipate in the discharge instructions? Select all that apply.

rest, increased fluids, saline gargles, antitussives

The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?

administer OTC decongestant

The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?

hoarseness for 2 weeks

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?

i was chewing ice chips all day long

The nurse is caring for a client in a physician's office whose x-ray of the sinus reveals exudate in the maxillary sinus. Which equipment must the nurse have present in the room?

irrigation equipment

A client recently diagnosed with laryngeal cancer and awaiting a laryngectomy was encouraged to attend a support group prior to surgery. The client asked the nurse about the name of the laryngeal speech method where the client speaks through the wall of the trachea with a device. The nurse is correct to provide teaching on which method?

A tracheoesophageal puncture

A client comes into the emergency department with epistaxis. What intervention should you perform when caring for a client with epistaxis?

Apply direct continuous pressure.

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply.

Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 Nasal flaring with abdominal retractions lung sounds of stridor increased respiratory effort

You are performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would you ask the client about the use of herbal supplements?

They prolong bleeding

You are caring for a client who is post-sinus surgery. When you assess this client, you ask him how many fingers you are holding up. Why do you assess postoperative visual acuity?

To assess damage to the optic nerve

A nurse is caring for a client following nasal surgery. Which assessment finding best indicates current bleeding?

frequent swallowing

You are an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would you be sure to include in your workshop? Select all that apply.

alcohol, tobacco, industrial pollutants

You are mentoring a new graduate nurse. Today, the two of you are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would you respond? Select all that apply.

aspiration, infection, injury to laryngeal nerve

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

The nurse is providing discharge instructions to a client diagnosed with postoperative tonsillectomy and adenoidectomy. Which discharge instructions would the nurse include? Select all that apply

avoid carbonated fluids gradually increased fluids then soft foods apply ice collar to neck area gargle with warm saline water

The nurse is receiving the post-tonsillectomy and post-adenoidectomy client in the postanesthesia care unit (PACU). The nurse aide is assisting the client from the stretcher to the bed. The client remains drowsy from anesthesia. In which position would the nurse instruct the nurse aide to place the client?

on a side

The nurse is caring for a client with an upper respiratory disorder. The client states he have a hacky, nonproductive cough, which wakens him during the night. Which over-the-counter medication would the nurse suggest to diminish the cough during the night?

robitussin

The nurse is providing suggestions to a client diagnosed with the effects of coryza. Which home remedy is appropriate when combined with medical treatment for pharyngitis?

salt water gargle