Management of Patients with Upper Resp Tract Disorders (Ch. 18) PREPU

The nurse is mentoring a new graduate nurse and the two are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. Which complication(s) would the nurse identify for the new nurse? Select all that apply.

1) Aspiration 2) Infection 3) Injury to the laryngeal nerve

An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by periods of breathing cessation for:

10 seconds with 5 episodes/hour.

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.

A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks?

Applying nasal packing

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 Explanation: Common side effects of budesonide (Rhinocort) include epistaxis, pharyngitis, cough, nasal irritation, and bronchospasm.

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is

Ineffective airway clearance related to excess mucus production

A patient is diagnosed as being in the early stage of laryngeal cancer of the glottis with only 1 vocal cord involved. For what type of surgical intervention will the nurse plan to provide education?

Partial laryngectomy

A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first

Stands behind the worker, who has hands across the neck

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 Hemorrhage or massive bleeding from the nose is called epistaxis. Initial interventions include having the client sit upright with the head tilted forward to prevent swallowing and aspiration of blood. Tilting the head back will encourage the client to swallow and possibly aspirate blood. Pressure is applied to the soft outer portion of the nose against the midline septum, not the upper and hard portion of the nose. Pressure is also applied continuously for 5 to 10 minutes.

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?

a feeling of swelling at the back of the throat

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

Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?

impaired verbal communciation

The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid

swimming.

Wound drains, inserted during the laryngectomy, stay in place until what criteria are met?

Drainage is <30 mL/day for 2 consecutive days.

Which clinical manifestation of hemorrhage is related to carotid artery rupture?

Increased pulse rate The nurse monitors vital signs for changes, particularly increased pulse rate, decreased blood pressure, and rapid, deep respirations. Cold, clammy, pale skin may indicate active bleeding.

The nurse is performing preoperative teaching with a client who has cancer of the larynx. After explaining the most important information, what is the nurse's best action?

Provide the client with audiovisual materials about the surgery.

Laryngeal cancer S&S

- swelling or lump in throat - followed by dysphagia - pain when talking

A client has a nursing diagnosis of acute pain related to upper airway irritation. The best short-term goal for this client is for the client to

Report relief of pain to level 3 using a pain intensity scale of 0 to 10.

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." Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apne

A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about?

Amoxicillin-clavulanic acid Treatment of acute rhinosinusitis depends on the cause; a 5- to 7-day course of antibiotics is prescribed for bacterial cases. Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid ( Augmentin) is the antibiotic of choice. Other antibiotics prescribed previously to treat ABRS, including cephalosporins such as cephalexin (Keflex), cefuroxime (Ceftin), cefaclor (Ceclor), and cefixime (Suprax), trimethoprim-sulfamethoxazole (Bactrim, Septra), and macrolides such as clarithromycin (Biaxin) and azithromycin (Zithromax), are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.

The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care

Apply an ice pack. Following a nasal fracture, the nurse applies ice and encourages the client to keep the head elevated. The nurse instructs the client to apply ice packs to the nose to decrease swelling. The packing inserted to stop the bleeding may be uncomfortable and unpleasant, and obstruction of the nasal passages by the packing forces the client to breathe through the mouth. This, in turn, causes the oral mucous membranes to become dry. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. Applying direct pressure is not indicated in this situation nasal pressure not indicated in this situation because pt's nose is fractured but not bleeding

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 severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.

An adolescent client sustains a fractured nose during a high school basketball game. Which action will the school nurse take first to help this client?

Apply ice with the client in a seated position. Explanation: Nasal fracture is the most common facial fracture and the most common fracture in the body. The signs and symptoms of a nasal fracture are pain, bleeding from the nose externally and internally into the pharynx, swelling of the soft tissues adjacent to the nose, periorbital ecchymosis, nasal obstruction, and deformity. The client's nose may have an asymmetric appearance that may not be obvious until the edema subsides. Immediately after the fracture, ice is applied and the client is instructed to keep the head elevated. The client should then be taken for emergency care when rolled gauze pads may be used to stop bleeding. Resetting of the nose may not occur for 3 to 7 days after the injury because of the edema.

The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client?

Avoid sports activities for 6 weeks.

Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?

Continuous positive airway pressure (CPAP)

Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require?

Emotional support

A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes

Gastroesophageal reflux disease (GERD) The nurse should ask whether the client has a medical history of GERD. Laryngitis is common in older adults and may be secondary to GERD. Older adults are more likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. COPD, CHF, and RF are not associated with laryngitis in the older adult

A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis?

Group A, beta-hemolytic streptococcus The adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. Infection of the adenoids frequently accompanies acute tonsillitis. Frequently occurring bacterial pathogens include group A, beta-hemolytic streptococcus, the most common organism.

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 caring for a client admitted with a diagnosis of bacterial pharyngitis. The nurse anticipates the client will be ordered which medication?

Penicillin The treatment of choice for bacterial pharyngitis is penicillin. Penicillin V potassium taken for 5 days is the regimen of choice. Traditionally, penicillin was administered as a single injection; however, oral forms are now used more often and are as effective as and less painful than injections. Penicillin injections are recommended only if there is a concern that the client will not comply with therapy. Robitussin DM may be used as an antitussive. Aspirin or Tylenol, or Tylenol with codeine, may be given for severe sore throats.

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

A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever, and dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may predispose the client to sinusitis?

interference with sinus drainage

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. Laryngeal cancer is one of the most preventable types of cancer; it can be prevented by abstaining from excessive drinking and smoking. Inhaling noxious fumes, such as in polluted air, is a risk factor for laryngeal cancer. Roughly 80% of laryngeal cancer cases occur in men. Squamous cell carcinoma accounts for most cases of laryngeal cancer.

nose fracture with epistaxis nursing task:

nasal packing to control bleeding A nasal fracture very often produces bleeding from the nasal passage. As a rule, bleeding is controlled with the use of packing.

A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for

nuchal rigidity

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

sinus infection. Explanation: Clients with nasotracheal and nasogastric tubes in place are at risk for developing sinus infections. Thus, accurate assessment of clients with these tubes is critical. Removal of the nasotracheal or nasogastric tube as soon as the client's condition permits allows the sinuses to drain, possibly avoiding septic complications. Severe epistaxis is not a complication of nasotracheal placement. Subperiosteal abscess and orbital cellulitis are complications of chronic rhinosinusitis.

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.

Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has?

Laryngeal cancer

The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

Noisy breathing

Late complications of radiation therapy may include which of the following? Select all that apply. (3)

Laryngeal necrosis Edema Fibrosis

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 Explanation: Hoarseness of more than 2 weeks' duration occurs in the patient with cancer in the glottic area because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh, raspy, and lower in pitch. However, affected voice sounds are not always early signs of subglottic or supraglottic cancer. The patient may report a persistent cough or sore throat and pain and burning in the throat, especially when consuming hot liquids or citrus juices. A lump may be felt in the neck. Later symptoms include dysphagia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath.

The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs?

Initiate enteral feedings. rationale: postoperatively, pt not permitted to eat or drink for at least 7 days. alternative sources of nutrition and hydration IV fluids, enteral feedings, parenteral nutrition

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?

The nasal mucosa Explanation: The nurse inspects the nasal mucosa for abnormal findings such as increased redness, swelling, exudate, and nasal polyps, which may develop in chronic rhinitis. The mucosa of the nasal turbinates may also be swollen (boggy) and pale bluish-gray. The nurse palpates the frontal and maxillary sinuses for tenderness, which suggests inflammation, and then inspects the throat by having the patient open the mouth wide and take a deep breath.

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

dysphagia dyspnea persistent hoarseness

The nurse assesses a client who has a nasogastric tube for long-term nutritional needs for complications associated with the medical device. The nurse monitors the client for _____ , a finding indicative of ________

purulent nasal drainage, rhinosinusitis Clients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Purulent nasal drainage is a symptom the nurse monitors for when assessing for complications associated with a nasogastric tube. Clients who require nasogastric tube feedings are at risk for rhinosinusitis; thus, the nurse monitors the client for purulent nasal drainage. Polyphagia and muscle weakness are not symptoms indicative of a complication related to the client's nasogastric tube. Aspiration, not viral pneumonia, is a complication associated with nasogastric tube feedings. Although a nasogastric tube can irritate the client's throat, bacterial pharyngitis is not a complication that is associated with this form of nutrition administration.

A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?

Group A, beta-hemolytic streptococci

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub?

20 mL or less

A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube?

The ET tube will maintain your airway while you're under anesthesia."

A client exhibits a sudden and complete loss of voice and is coughing. The nurse states

"Do not smoke and avoid being around others who are smoking."

A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to

Check the clear fluid for glucose. Explanation: The client's signs and symptoms are consistent with a fracture of the nose. Clear fluid draining from either nostril suggests leakage of cerebrospinal fluid. This can be checked by assessing for glucose, which is in cerebrospinal fluid. This finding is important to identify, because infection can be transmitted through the opening in the cribriform plate. Other options, such as applying an ice pack to the nose and administering ibuprofen, are appropriate interventions but not most important for this client. Reassuring the client that the nose is not fractured is premature until all assessments are completed.