Chapter 27 upper respiratory problems

38. A patients tracheostomy tube becomes dislodged with vigorous coughing. What should be the nurses first action? a. Attempt to replace the tube b. Notify the health care provider c. Place the patient in high Fowler position d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives

ANS: A If a tracheostomy tube is dislodged, the nurse should immediately attempt to replace the tube by grasping the retention sutures (if available) and spreading the opening. The obturator is inserted in the replacement tube, water-soluble lubricant is applied to the tip, and the tube is inserted in the stoma as a 45-degree angle tot eh neck. The obturator is immediately removed to provide an airway. If the tube cannot be reinserted, the health care provider should be notified and the patient should be assessed for the level of respiratory distress, positioned in semi-Fowler position, and ventilated with a manual resuscitation bag (MRB) only if necessary until assistance arrives.

18. The nurse is caring for a hospitalized older 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 patient's temperature is 100.1° F (37.8° C). d.The patient complains of level 8 (0 to 10 scale) pain.

ANS: A Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the low O2 saturation.

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

ANS: A The patient's clinical manifestation of a muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems.

7. 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."

ANS: A Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy.

31. While the nurse is feeding a patient, the patient appears to choke on the food. Which symptoms indicate to the nurse that the patient has a partial airway obstruction (select all that apply)? a. stridor b. Cyanosis c. Wheezing d. Bradycardia e. Rapid respiratory rate

ANS: A,B,C With partial airway obstruction, choking, stridor, use of accessory muscles, suprasternal and intercostals retraction, flaring nostrils, wheezing, restlessness, tachycardia, cyanosis, and change in level of consciousness may occur. Partial airway obstruction may progress to complete obstruction without prompt assessment and treatment.

37. What is included in the nursing care of the patient with a cuffed tracheostomy tube? a. Change the tube 3 days b. Monitor cuff pressure every 8 hours c. Perform mouth care every 12 hours d. assess arterial blood gases every 8 hours

ANS: B Cuff pressure should be monitored every 8 hours to ensure an air leak around the cuff does not occur and that the pressure is not to high to allow adequate tracheal capillary perfusion. Respiratory therapists in some institutions will record the cuff pressure and identify if there is a problem maintaining cuff pressure. Tracheostomy tubes are not usually changed sooner than 7 days after a tracheostomy. Mouth care should be performed a minimum of every 8 hours and more often as needed to remove dried secretions. ABGs are not routinely assessed with tracheostomy tube placement unless symptoms of respiratory distress continue.

27. What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? a. Undergo weekly immunotherapy b. Identify and avoid triggers of the allergic reaction c. Use cromolyn nasal spray prophylactically year-round d. Use over-the-counter antihistamines and decongestants during an acute attack

ANS: B The most important factor in managing allergic rhinitis is identification and avoidance of triggers of the allergic reactions. Immunotherapy may be indicated if specific allergens are identified and cannot be avoided. Drug therapy is an alternative to avoidance of the allergens but long-term use of decongestants can cause rebound nasal congestion.

30. A patient with an acute pharyngitis is seen at the clinic with fever and severe throat pain that affects swallowing. On inspection, the throat is reddened and edematous with patchy yellow exudates. The nurse anticipates that collaborative management will include? a. treatment with antibiotics b. treatment with anti fungal agents c. a throat culture or rapid strep antigen test d. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days.

ANS: C Although inadequately treated B-hemolytic streptococcal infections may lead to rheumatic heart disease or glomerulonephritis, antibiotic treatment is not recommended until strep infections are definitely diagnosed with culture or antigen tests. The manifestations of viral and bacterial infections are similar and appearance in not diagnostic except when the white irregular patches on the oropharynx suggest that candidiasis is present.

10. 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."

ANS: C Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.

43. Following a supraglottic laryngectomy, the patient is taught how to use the supraglottic swallow to minimize the risk of aspiration. In teaching the patient about this technique, what should the nurse instruct the patient to do? a. Perform Valsalva maneuver immediately after swallowing b. Breath between each Valsalva maneuver and cough sequence c. Cough after swallowing to remove food from the top of the vocal cords. d. Practice swallowing thin, watery fluids before attempting to swallow solid foods

ANS: C Supraglottic laryngectomy involves removal of the epiglottis and false vocal cords and the removal of the epiglottis allows food to enter to trachea. Supraglottic swallowing protects the trachea from aspiration by taking a deep breath, putting the food or fluid in the mouth, swallowing while holding the breath, coughing immediately after swallowing to remove the food from the top of the vocal cord, swallowing again, then breathing. Super-supraglottis swallowing requires performance of the Valsalva maneuver before placing food in the mouth and swallowing.

3. The nurse discusses management of upper respiratory infections (URI) 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."

ANS: C 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

4. A nurse who is caring for 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. Preoxygenate the patient for 3 minutes before suctioning.

ANS: C 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. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.

26. The nurse receives an evening report on a patient who underwent posterior nasal packing for epistaxis earlier in the day. What is the first patient assessment the nurse should make? a. Patients temperature b. Level of the patients pain c. Drainage on the nasal dressing d. Oxygen saturation by pulse oximetry

ANS: D All of the assessments are appropriate but the most important is the patients oxygen status. After the posterior nasopharynx is packed, some patients, especially older adults, experience a decrease in PaO2 and an increase in PaCO2 because of impaired respiration and the nurse should monitor the patient s respiratory rate and rhythm and SpO2.

2. 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.

ANS: D The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Acute viral rhinitis (the common cold) can be prevented by washing hands.

12. Which action should the nurse take first when a patient develops a nosebleed? 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 compresses over the patient's nose and cheeks.

ANS: A The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area, but will not be sufficient to stop bleeding. Cauterization and nasal packing are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed.

1. The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)? a.Decongestants can be used to relieve 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 your head in an upright position.

ANS: A, C, D, E The steam and heat from a shower will help thin secretions and improve drainage. Decongestants can be used to relieve swelling. Patients can use either over-the-counter (OTC) sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.

34. During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. To Care for the tracheostomy appropriately, what should the nurse do? a. Deflate the cuff, then remove and suction the inner cannula b. Remove the inner cannula and replace it per institutional guidelines c. Remove the inner cannula if the patient shows signs of airway obstruction d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube

ANS: B An inner cannula is a second tubing that fits inside the outer tracheostomy tube. Disposable inner cannulas are frequently used but non disposable ones can be removed and cleaned of mucus that has accumulated on the inside of the tube. Many tracheostomy tubes do not have inner cannulas because when humidification is adequate, accumulation of mucus should not occur.

5. 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.

ANS: C 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. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube.

32. What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? a. A tracheostomy is safer to perform in an emergency. b. An ET tube has a higher risk of tracheal pressure necrosis c. A tracheostomy tube allows for more comfort and mobility d. An ET tube is more likely to lead to lower respiratory tract infection

ANS: C With a tracheostomy, patient comfort is increased because there is n tube in the mouth. Because the tube is more secure, mobility is improved. The ET tube is more easily inserted in an emergency situation, It is perforable to perform a tracheostomy in an operating room because it requires careful dissection but it can be performed with local anesthetic in the intensive care unit or in and emergency. With a cuff, tracheal pressure necrosis is as much a risk with a tracheostomy tube as with an ET tube and infection is also as likely to occur because the defenses of the upper airway are bypassed.

20. 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 health care provider. 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.

ANS: D Because the highest priority action is to remove the foreign object from the nare, the nurse's first action should be to assist the patient to remove the object. The other actions are also appropriate but should be done after attempting to clear the nose.

28. During assessment of the patient with a viral upper respiratory infection, the nurse recognizes that antibiotics may be indicated based on what finding? a. Cough and sore throat b. Copious nasal discharge c. Temperature of 100F (38C) d. Dyspnea and severe sinus pain

ANS: D Dyspnea and severe sinus pain as we'll as tender swollen glands, severe ear pain, or significantly worsening symptoms in a patient who has a viral upper respiratory infection (URI) indicate lower respiratory involvement and a possible secondary bacterial infection. Bacterial infections are indications for antibiotic therapy but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. Low-grade elevated temperature, cough, sore throat, myalgia, and purulent nasal drainage at the end of a cold are common symptoms of viral rhinitis and influenza.

35. Which actions prevent the dislodgment of a tracheostomy (select all that apply)? a. Provide tracheostomy care every 24 hours b. Keep the patient in the semi-Fowler position at all times c. Keep a same size or larger replacement tube at the bedside d. Tracheostomy ties are not changed for 24 hours after tracheostomy produce e. Suction the tracheostomy tube when there is a moist cough or a decreased SpO2 f. A physician performs the first tube change, no sooner than 7 days after the tracheostomy

ANS: D, E, F Changing the tracheostomy tapes or the tube to soon will be irritating to the trachea and could contribute to dislodgment of the tracheostomy tube. Suctioning should be done when increased secretions are evident in the tube to prevent the patient from severe coughing, which could cause tube dislodgment. Tracheostomy care is done every 8 hours. Keeping the patient in a semi-Fowler position will not prevent dislodgment. Keeping and extra tube at the bedside will speed reinsertion if the tracheotomy tube is dislodged but it will not prevent dislodgment.

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

ANS: A Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate any complications.

25. A patient develops epistaxis upon removal of a nasogastric tube. What action should the nurse take? a. Pinch the soft part of the nose b. Position the patient on the side c. Have the patient hyperextened the neck d. Apply an ice pack to the back of the neck

ANS: A Direct pressure on the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes is indicated for epistaxis. In addition, have the patient upright and leaning forward to prevent swallowing blood.

21. 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 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 patient to "swish and swallow" prescribed oral nystatin (Mycostatin).

ANS: D Oral or pharyngeal fungal infections are treated with nystatin solution. The goal of the "swish and swallow" technique is to expose all of the oral mucosa to the antifungal agent. Warm liquids may be soothing to a sore throat. The patient should be taught to use a cool mist humidifier. There is no need to assess for penicillin/cephalosporin allergies because Candida albicans infection is treated with antifungals.

42. When assessing the patient on return to the surgical unit following a total laryngectomy and radical neck dissection, what would the nurse expect to find? a. A closed-wound drainage system b. A nasal endotracheal tube in place c. A nasogastric tube with orders for tube feeding d. A tracheostomy tube and mechanical ventilation

ANS: A Following a radical neck dissection, drainage tubes are often used to prevent fluid accumulation in the wound as well as possible pressure on the trachea. The patient has placement of a nasogastric tube to suction immediately after surgery, which will later be used to administer tube feeding until swallowing can be accomplished. A tracheostomy tube is in place but mechanical ventilation is usually not indicated.

33. What are the characteristics of a fenestrated tracheostomy tube(select all that apply)? a. The cuff passively fills with air b. Cuff pressure monitoring is not required c. It has two tubings with one opening just above the cuff d. Patient can squeak with an attached air source with the cuff inflated e. Airway obstruction is likely if the exact steps are not followed to produce speech f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted

ANS: E,F The fenestrated tracheostomy tube has openings on the outer cannula to allow air to pass over the vocal cords to allow speaking. If the steps of using the fenestrated tracheostomy tube are not completed in the correct order, severe respiratory distress may result. The cuff of the tracheostomy tube with a foam-filled cuff passively fills with air and does require pressure monitoring, although cuff integrity must be assessed daily. The speaking tracheostomy tube has two tubes attached. One tube allows air to pass over the vocal cords to enable the person to speak with the cuff inflated.

40. The patient has been diagnosed with an early vocal cord malignancy. The nurse explains that usual treatment includes? a. Radiation therapy that preserves the quality of the voice b. a hemilaryngectomy that prevents the need for a tracheostomy c. a radical neck dissection that removes possible sites of metastasis d. a total laryngectomy yo prevent development of second primary cancers

ANS: A If laryngeal tumors are small, radiation is the treatment of chronic because it can be curative and can preserve voice quality. Surgical procedures are used if radiation treatment is not successful or if larger or advanced lesions are present.

6. 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.

ANS: A 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. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patient's airway is occluded. A health care provider's order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings.

8. 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?"

ANS: A Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients with this type of infection will also have pain and a fever.

29. A 36-year-old patient with type 1 diabetes mellitus asks the nurse whether an influenza vaccine is necessary every year. What is the best response by the nurse? a. "You should get the trivalent inactivated influenza vaccine that is injected every year." b. "Only health care workers in contact with high-risk patients should be immunized each year." c. "An annual vaccination is not necessary because previous immunity will protect you for several years." d. "Antiviral drugs, such as zanamivir (Relenza), eliminate the need for vaccine except in the older adult."

ANS: A The injected trivalent inactivated influenza vaccine is recommended for individuals 6 months of age and older and those at increased risk for influenza-related complications, such as people with chronic medical conditions or those who are immunocompromised, residents of long-term care facilities, health care workers, and providers of care to at-risk-persons. The live attenuated influenza vaccine is given intranasally and is recommended for all healthy people between the ages of 2 and 49 but not for those at increased risk of complications or health care providers. The immunity will not protect for several years, as new strains of influenza may develop each year. Antiviral agents will help to reduce the duration and severity of influenza in those at high risk but immunization is the best control.

11. 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."

ANS: A The stoma may be covered with clothing or a loose dressing, but this is not essential. An occlusive dressing will completely block the patient's airway. The other patient comments are all accurate and indicate that the teaching has been effective.

41. During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include? a. The postoperative use of of nonverbal communicate techniques b. Techniques that will be used to alleviate a dry mouth and prevent stomatitis c. The need for frequent, vigorous coughing in the first 24 hours postoperativity d. Self-help groups and community resources for parties with cancer of the larynx

ANS: A With removal of the larynx, the patient will not be able to communicate verbally and it is important to arrange with the patient a method of communication before surgery so that postoperative communication can take place. Dry mouth and stomatitis result from radiation therapy. Vigerious coughing is not encouraged immediately postoperatively and information related to community resources is usually introduced during the postoperative period.

36. In planning the care for a patient with a tracheostomy who has been stable and is to be discharged later in the day, the RN may delegate which interventions to the licensed practical nurse (LPN)(select all that apply)? a. Suction the tracheostomy b. Provide tracheostomy care c. Determine the need for suctioning d. Assess the patients swallowing ability e. Teach the patient about home tracheostomy care

ANS: A, B, C LPN's may determine the need for suctioning, suction the tracheostomy, and determine whether the patient has improved after the suctioning when caring for stable patients. They also may perform tracheostomy care using sterile technique. The patients swallowing ability is assessed by a speech therapist, videofluroscopy, or fiberoptic evaluations. The RN will teach the patient about home tracheotomy care.

2. The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)? a.A 76-year-old nursing home resident b.A 36-year-old female patient who is pregnant c.A 42-year-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-year-old patient who has allergies to penicillin and cephalosporins

ANS: A, B, D Current guidelines suggest that healthy individuals between 6 months and age 49 receive intranasal immunization with live, attenuated influenza vaccine. Individuals who are pregnant, residents of nursing homes, or are immunocompromised or who have chronic medical conditions should receive inactivated vaccine by injection. The corticosteroid use by the 30-year-old increases the risk for infection.

17. Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? a.Assess the patient's 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.

ANS: B Suctioning of a stable patient can be delegated to LPNs/LVNs. Patient assessment and patient teaching should be done by the RN.

44. What should the nurse include in discharge teaching for the patient with a total laryngectomy? a. How to use esophageal speech to communicate b. How to use a mirror to suction the techeaostomy c. The necessity of never covering the laaryngectomy stoma d. The need to use baths instead of showers for personal hygiene

ANS: B Suctioning of the tracheostomy with the use of a mirror is a self-care activity taught to the patient before discharge. Voice rehabilitation is usually managed by a speech therapist or speech pathologist but the nurse should discuss the various types of voice rehabilitation and the advantages and disadvantages of each options. The laryngectomy stoma should be covered with a shield during showering and covered with light scarves or fabric when aspiration of foreign materials is likely.

16. 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 health care provider? a.Fever of 100.4° F (38° C) b.Diffuse crackles in the lungs c.Sore throat and frequent cough d.Myalgia and persistent headache

ANS: B The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical manifestations of influenza and are treated with supportive care measures such as over-the-counter (OTC) pain relievers and increased fluid intake.

14. Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a.Cover stoma with sterile gauze and ventilate through stoma. b.Attempt to reinsert the tracheostomy tube with the obturator in place. c.Assess the patient's oxygen saturation and notify the health care provider. d.Ventilate the patient with a manual bag and face mask until the health care provider arrives.

ANS: B The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.

22. When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), 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 any inhalers. d.Teach the patient to avoid use of nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: B The patient's clinical manifestations are consistent with streptococcal pharyngitis and the nurse will anticipate the need for a rapid strep antigen test and/or cultures. Because patients with streptococcal pharyngitis usually do not have a cough, use of expectorants will not be anticipated. Rinsing the mouth out after inhaler use may prevent fungal oral infections, but the patient's assessment data are not consistent with a fungal infection. NSAIDs are frequently prescribed for pain and fever relief with pharyngitis.

39. When Obtaining a health history from a patient with possible cancer of the mouth, what would the nurse expect the patient to report? a. Long-term denture use b. Heavy tobacco and/or alcohol use c. Persistent swelling of the neck and face d. Chronic herpes simplex infections of the mouth and lips

ANS: B The primary risk factor associated with head and neck cancers are heavy tobacco and alcohol use and family history. Chronic infections are not known to be risk factors, although cancers in patients younger than age 50 have been associated with human papillomavirus (HPV) infection. oral cancer may cause a change in the fit of dentures but denture use is not a risk factor for oral cancer.

45. What is the most normal functioning method of speech restoration in the patient with a total laryngectomy? a. Esophageal speech b. A transesophageal puncture c. An electrolarynx held to the neck d. An electrolarynx palced in the mouth

ANS: B Transesophageal puncture provides the most normal voice reproduction but requires a surgical fistula made between the esophagus and the trachea and possibly a valve prosthesis. Esophageal speech involves trapping air in the esophagus and releasing it to form sound but only 10% of patients can develop fluent speech with this method. The electrolarynx, whether placed in the mouth or held to the neck, allows speech that has a metallic or robotic sound.

1. The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful? a."I can take 800 mg ibuprofen 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 hours to minimize swelling and pain."

ANS: D 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 patient would not be taught to remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result, especially in the first few weeks after surgery.

13. A 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-Fowler's position.

ANS: D The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube.

9. A patient scheduled for a total laryngectomy 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 won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." c."You won't be able to speak as you used 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."

ANS: D Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.