Chapter 31 - Care of Patients with Noninfectious Upper Respiratory Problems

Integrated Process: Teaching/Learning 7. Which client does the nurse safely delegate to the LPN/LVN who has been assigned to the unit for the first time? a. Young adult who is 6 hours post radical neck dissection b. Older adult client with esophageal cancer who is awaiting gastric tube placement c. Client who is status post laryngectomy and is awaiting discharge teaching d. Client who is awaiting preoperative teaching for laryngeal cancer

B The nurse can delegate stable clients to the LPN. The client who is 6 hours post surgery is not yet stable. The RN is the only one who can perform discharge and preoperative teaching. Teaching cannot be delegated. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Delegation)

1. A high school athlete has suffered a nasal fracture. What is the priority action of the nurse caring for the client? a. Assess for pain. b. Pack the nares to prevent blood loss. c. Assess for bone displacement. d. Assess for airway patency.

D A patent airway is the priority. The nurse first should make sure that the airway is patent, then should determine whether the client is in pain, and whether bone displacement or blood loss has occurred. DIF: Cognitive Level: Application/Applying or higher TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Teaching/Learning 15. The nurse is observing a client performing stoma care for a laryngectomy for the first time. Which action does the nurse reinforce? a. Washing the stoma with soap and water b. Covering the stoma with a gauze pad c. Irrigating the stoma with half-strength peroxide d. Making sure any scab around the stoma is removed

A The client is taught to wash the stoma gently and to prevent anything from getting into the opening. The client should never scrape around the opening because this could cause broken skin, irritation, and infection. Peroxide is not used for irrigation; irrigation of the stoma is not done. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Teaching/Learning 10. What is the highest priority for the nurse to teach the client who is being discharged after a fixed centric occlusion for a mandibular fracture? a. How to use wire cutters b. Eating six soft or liquid meals each day c. How to irrigate the mouth every 2 hours d. Sleeping in semi-Fowler's position postoperatively

A The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. Although the client will need to sleep in a semi-Fowler's position to assist in avoiding aspiration if vomiting does occur, this will not be as high a priority as knowing how to cut the wires. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Assessment) 5. A client had a partial laryngectomy and has received instructions on the supraglottic method of swallowing. Which action by the nurse is most appropriate? a. Place a chart in the client's room detailing the steps in the process. b. Order a dynamic swallow study. c. Repeat the instruction each day. d. Have the client demonstrate swallowing.

A The client who is status post partial laryngectomy should be taught alternative methods of swallowing, and a chart should be placed in the client's room to reinforce teaching. A dynamic swallow study is performed to guide rehabilitation for swallowing. Repeating the steps each shift is not as effective as showing the client a chart. Having the client demonstrate swallowing may not verify that he or she correctly understands supraglottic swallowing. A chart in the room will be most effective in helping both client and staff with this method. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 2. After facial trauma, a client has a nasal fracture and is reporting constant nasal drainage, a headache, and difficulty with vision. What is the nurse's first action? a. Collect the nasal drainage on a piece of filter paper. b. Send the client for a facial x-ray. c. Perform a vision test. d. Palpate all facial areas for crepitus.

A The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebral spinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the client's risk for infection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) MULTIPLE RESPONSE 1. The nurse is assessing a client who is 6 hours post surgery for a nasal fracture. The client has facial pain (5 out of 10) and nasal packing in place. What actions by the nurse are most appropriate at this time? (Select all that apply.) a. Observe for clear drainage. b. Observe for bleeding. c. Observe the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing. g. Administer pain medication. h. Place the client in Trendelenburg position.

A, B, C, D, G The nurse should observe for clear drainage because of the risk for cerebrospinal fluid (CSF) leakage. The nurse should note whether the client is swallowing frequently because this could indicate postnasal bleeding. The nurse should also ask the client to open his or her mouth and should observe the back of the throat for bleeding. Pain medication should also be administered. It is too soon to change the packing, which should be changed by the surgeon the first time. A nasal steroid would increase the risk for infection. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 2. The client with which conditions requires immediate nursing intervention? (Select all that apply.) a. Shortness of breath b. Sternal retractions c. Pulse oximetry reading of 95% d. Occasional expiratory wheeze e. Respiratory rate of 8 breaths/min f. Arterial blood gas showing a pH of 7.35 g. Stridor

A, B, E, G The client with sternal retraction is experiencing serious respiratory difficulty, as is the client with stridor. The client who reports shortness of breath needs immediate assessment, as does the client with a respiratory rate of 8. A pulse oximetry of 95% is within normal limits, as is a pH of 7.35. The client with expiratory wheezes needs to be assessed, but not immediately. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies)

Integrated Process: Nursing Process (Assessment) 4. The nurse is assessing a client with facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin

A, D Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis or bruising behind the ear is called "battle sign" and indicates basilar skull fracture. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)

Integrated Process: Teaching/Learning 8. A client has a closed fracture of the nose. Which intervention is best when encouraging self-care for this client? a. Advise the client not to eat or drink for 24 hours after sustaining the fracture. b. Teach the client how to apply cold compresses to the area to reduce swelling. c. Urge the client to sleep without a pillow to hasten resolution of the swelling. d. Reassure the client that his or her appearance will normalize after the swelling is gone.

B After a closed fracture of the nose, the nurse will encourage rest and the use of cool compresses on the nose, eyes, or face to help reduce swelling and bruising. Avoiding eating or drinking and sleeping without a pillow will not hasten resolution of the swelling. Reassuring the client regarding his or her appearance is not included in self-care. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Teaching/Learning 9. Which statement indicates that the client needs more teaching regarding rhinoplasty? a. "I will take my temperature twice each day and will report any fever to my doctor." b. "I will wait a few weeks to have my photograph taken, when the swelling is gone." c. "I will take acetaminophen instead of aspirin for pain to avoid excessive bleeding." d. "I will drink at least 3 quarts of liquids a day and will use a stool softener."

B Explain that edema and bruising may last for weeks, and that the final surgical result will be evident in 6 to 12 months. The client should take his or her temperature and report fever in case of infection. The client should take acetaminophen because risk of bleeding is less than with aspirin. Fluids and stool softeners will decrease the risk of straining. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Teaching/Learning 6. A client has open vocal cord paralysis. Which technique does the nurse teach the client to do to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Tuck the chin down when swallowing. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing.

B The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration, but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Implementation) 18. A client who has sleep apnea is reporting constant daytime sleepiness. The client has multiple other chronic diseases. What is the nurse's best action? a. Refer the client for surgery. b. Perform a health history. c. Request an order for a sleeping pill. d. Move the client to a private room.

B The nurse should first assess the client and determine whether he or she has other chronic diseases. If the client's other disorders are not contradictory, the client may be eligible for therapy with modafinil (Attenace) to increase wakefulness during the day. Certain cardiac disorders may prohibit the use of this drug owing to its simulative effects. A sleeping pill would not be an appropriate intervention for a client with sleep apnea. A private room will not help to increase the client's sleep in sleep apnea. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management)

Integrated Process: Nursing Process (Assessment) 13. Which statement made by the client who is prescribed "voice rest" therapy for vocal cord polyps indicates the need for more teaching? a. "I will stay out of rooms and places where people are smoking." b. "When I speak at all, I will whisper rather than use a normal tone of voice." c. "For the next several weeks, I will not lift more than 10 pounds." d. "I will drink at least 3 quarts of water each day and will use stool softeners."

B Treatment for vocal cord polyps includes not speaking, no lifting, and no smoking. The client has to be educated not to even whisper when resting the voice. It is also appropriate for the client to stay out of rooms where people are smoking, and to stay hydrated and use stool softeners. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Assessment) 3. A client develops epistaxis. Which conditions in the client's history could have contributed to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets g. High cholesterol

B, C, D Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures. Diabetes, migraine, and elevated platelets and cholesterol levels do not cause epistaxis. DIF: Cognitive Level: Comprehension/Understanding REF: p. 582 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)

Integrated Process: Teaching/Learning 11. Which client is at greatest risk for development of obstructive sleep apnea? a. Woman who is 8 months pregnant b. Middle-aged man with gastroesophageal reflux disease c. Middle-aged woman who is 50 pounds overweight d. Older man with type 2 diabetes and a history of sinus infections

C The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea. DIF: Cognitive Level: Comprehension/Understanding REF: p. 584 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems)

Integrated Process: Teaching/Learning 14. A client states that he is going to relax on the beach between radiation treatments for laryngeal cancer to help his "mental status." What is the nurse's best response? a. "You deserve to do something for yourself." b. "Make sure someone is with you because you shouldn't be alone right now." c. "Your skin can become severely burned, and you should not be out in the sun." d. "You should make sure you use sunscreen that is at least SPF 15."

C The client should stay out of the sun during treatment because the skin can become severely burned. Sunscreen may or may not help, but an SPF of 15 is low and does not provide adequate prevention. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

Integrated Process: Nursing Process (Assessment) 12. Which clinical manifestation in a client with paralysis of one vocal cord alerts the nurse to the possibility of aspiration? a. Oxygen saturation is decreased. b. Voice is weak and tremulous. c. The client coughs immediately after swallowing. d. An audible wheeze is present on exhalation.

C The client with open vocal cord paralysis is at risk for aspiration because the airway may not close during swallowing. Coughing may indicate that the client's airway is irritated from aspirated contents. Decreased oxygen saturation can occur for a number of reasons. A weak voice may indicate weak muscles, and wheezing may indicate swelling or inflammation in the airways. DIF: Cognitive Level: Comprehension/Understanding REF: p. 585 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Teaching/Learning 16. A client has undergone a nasoseptoplasty 2 hours ago. It is a priority for the nurse to assess for which factor? a. Nasal drainage b. Bleeding c. Pain d. Airway patency

D Assessing and maintaining a patent airway is always the top priority. The other assessments are important but do not take priority over airway. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

Integrated Process: Nursing Process (Implementation) 4. A client reports waking up feeling very tired, even after 8 hours of good sleep. What is the nurse's best action? a. Ask for an order for sleep medication. b. Tell the client not to drink beverages with caffeine. c. Tell the client not to lie flat at night. d. Ask the client whether he or she has ever been evaluated for sleep apnea.

D Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

Integrated Process: Nursing Process (Implementation) 3. What is the nurse's most important action after a client's gag reflex has returned post rhinoplasty? a. Teach the client to change position every 2 hours. b. Tell the client to put heating pads on the face. c. Instruct the client to lay flat. d. Have the client drink at least 2500 mL/day.

D Once the gag reflex has returned, the client should drink at least 2 1/2 liters per day. The client should not change position frequently; the best position is semi-Fowler's. Ice rather than heat should be applied. Lying flat is not recommended. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

Integrated Process: Nursing Process (Assessment) 17. A client develops posterior nasal bleeding and has packing inserted. What is the nurse's priority action? a. Assess the client's pain level. b. Keep the client's head elevated. c. Teach the client about the causes of nasal bleeding. d. Make sure the string is taped to the client's cheek.

D The thread is attached to the client's cheek that holds the packing in place. The nurse needs to make sure that this does not move because it can occlude the client's airway. The other options are good interventions, but ensuring that the airway is patent is the priority objective. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests, Treatments, Procedures)