NUR 222 - Ch 9 OL study questions
A patient has a size 6 tracheostomy tube. Which size suction catheter would be used?
9-French.
Patients receiving tube feedings are positioned with the head of the bed at
30 degrees or higher during feedings
Cuff pressure on the endotracheal or tracheostomy tube should be monitored by the nurse at least every:
8 hours.
Which of the following nursing interventions should a nurse perform when caring for a patient with an endotracheal tube?
Clean teeth with applicators.
A patient is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include which of the following?
Hoarseness.
Which of the following are clinical manifestations associated with obstructive sleep apnea {OSA}? Select all that apply.
Insomnia; Arrhythmias; Loud snoring; Excessive daytime sleepiness; Impotence.
symptoms of radiation therapy that may occur earlier in treatment.
Loss of taste and xerostomia
The nurse is assessing a patient in the clinic. The patient, upon physical assessment, demonstrates displacement of the sternum. This would be documented as which of the following?
Pigeon chest.
Which of the following should a nurse assess in a patient who has undergone a sinus surgery?
Repeated swallowing.
Xerostomia refers to
dryness of the mouth.
Cyanosis is a late sign of
hypoxia.
Pigeon chest may occur with
rickets, Marfan's syndrome, or severe kyphoscoliosis.
In central sleep apnea, the patient demonstrates
simultaneous cessation of both airflow and respiratory movements.
postoperative instructions after a laryngeal surgery: The nurse also asks the patient to use a hand-held shower device
to keep water from entering the stoma
High cuff pressure can cause
tracheal bleeding, ischemia, and pressure necrosis.
During a supraglottic laryngectomy, a _____ is left in place until the _____ airway is established.
tracheostomy; glottic
True or false: Lip speaking does not resemble normal speech.
true
True or false: There is no type of sleep apnea classified as simple apnea.
true
Most cases of acute pharyngitis are caused by
viral infection.
Which of the following is an early complication of tracheostomy tube management? Select all that apply.
Bleeding; Air embolism; Subcutaneous emphysema.
Which of the following methods most resembles normal speech following a total laryngectomy?
Blom-Singer voice prosthesis.
When the patient who has undergone laryngectomy presents evidence of wound breakdown, the nurse monitors him very carefully because he is identified as being at high risk for which of the following?
Carotid artery hemorrhage.
Second-line therapy in the treatment of acute sinusitis includes
Ceftin, Cefzil, and Augmentin.
Sleep apnea that is characterized by simultaneous cessation of both airflow and respiratory movements is noted as which of the following?
Central.
Which of the following is the most effective treatment for obstructive sleep apnea {OSA}?
Continuous positive airway pressure {CPAP}.
Which of the following is a late sign of hypoxia?
Cyanosis.
Which of the following a priority nursing intervention that the nurse should perform for a patient who has undergone surgery for a nasal obstruction?
Ensure mouth breathing.
The nurse assesses a patient who is bleeding profusely from the nose. The nurse documents this finding as which of the following?
Epistaxis.
Which of the following is a late complication of radiation therapy?
Laryngeal necrosis.
Late complications of radiation therapy may include which of the following? Select all that apply.
Laryngeal necrosis; Edema; Fibrosis.
Mechanical ventilation is not the most effective treatment for
OSA.
Which type of sleep apnea is characterized by lack of airflow due to pharyngeal occlusion?
Obstructive.
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?
Partial laryngectomy.
Which of the following is the treatment of choice for bacterial pharyngitis?
Penicillin.
Which of the following is a complication of low cuff pressure on an endotracheal tube?
Risk of aspiration.
A patient who has an altered level of conscious is receiving a tube feeding. Patients receiving tube feeding should be placed into which of the following positions?
Semi-Fowler's or higher.
Which diagnostic test is used to confirm the diagnosis of maxillary and frontal sinusitis?
Sinus aspirates.
Which of the following postoperative instructions does a nurse provide a patient and family to avoid after a laryngeal surgery?
Swimming.
Which of the following is a true statement regarding a total laryngectomy?
There is a permanent loss of voice from a total laryngectomy.
True or False: Types of sleep apnea do not include a "simple" characterization.
True
With electrolarynx, a battery-powered apparatus projects sound into the oral cavity.
When the mouth forms words (articulation), the sounds from the electric larynx becomes audible words.
Cold, clammy skin may indicate
active bleeding.
For severe sore throats, _____ may be given.
aspirin or Tylenol, or Tylenol with codeine
Cuff pressure must be monitored how frequently?
at least every 8 hours
Dysphagia refers to
difficulties in swallowing.
Patients receiving tube feedings are positioned with the head of the bed elevated for how long after tube feedings?
for 30 to 45 minutes after tube feedings.
Sinus X-rays and CT scans may be obtained for patients with
frontal headaches, if complications are suspected.
Signs of acute laryngitis include
hoarseness or aphonia and severe cough.
rationale: The Blom-Singer voice prosthesis most resembles
normal speech.
The nurse should suction the _____ and the _____ as needed and clean the teeth with _____.
oropharynx, mouth; applicators
With esophageal speech, patients compress air into the esophagus and expel it, setting off a vibration of the
pharyngeal esophageal segment.
Hypoxia can cause
restlessness and an initial rise in blood pressure that is followed by hypotension and somnolence.
Current research evidence suggests feedings should be held if gastric residuals are greater than which of the following on two separate occasions?
200 mL (current research)
Evidence suggests feedings should be held if gastric residuals are greater than
200 mL (evidence suggests)
A first-line antibiotic utilized in the treatment of acute sinusitis includes which of the following?
Ampicillin.
Late symptoms of laryngeal cancer include which of the following. Select all that apply.
Dysphagia; Dyspnea; Persistent hoarseness.
Clinical manifestations of hemorrhage related to carotid artery rupture include which of the following?
Increased pulse rate.
The priority nursing diagnosis for the patient undergoing a laryngectomy includes which of the following?
Ineffective airway clearance.
The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as which of the following?
Pleural friction rub.
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, deep respirations.
The patient would need a 9-French suction catheter.
To calculate the catheter size needed, note the interior diameter {i.d.} of the tracheostomy tube, divide by two, and then multiply by three to obtain the French size.
Which of the following interventions regarding nutrition is implemented for patients who have undergone laryngectomy?
Use enteral feedings after the procedure.
Most cases of acute pharyngitis are caused by which of the following?
Viral infection.
Mixed apnea is
a combination of central and obstructive apnea within one apneic episode.
During a total laryngectomy, a complete removal of the _____ is performed, including the _____
a complete removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea.
Following a laryngectomy, the patient may experience anorexia related to
a diminished sense of taste and smell.
Other signs of acute laryngitis include
a dry cough and a throat that feels worse in the morning.
Obstructive apnea is
a lack of air flow due to pharyngeal occlusion.
Periorbital edema is assessed postoperatively in case of
a nasal fracture.
Septal hematoma is used to detect
a nasal fracture.
The nurse recommends the use of a splint and the application of pressure to the convex portion of the nose in case of
a nasal fracture.
a total laryngectomy results in
a permanent tracheostomy.
Central apnea is classified as
a simultaneous cessation of both air flow and respiratory movements.
Cold, clammy, pale skin may indicate
active bleeding.
Long-term complications of tracheostomy tube management include
airway obstruction, infection, and dysphagia.
First-line antibiotics in the treatment of acute sinusitis includes
amoxicillin, ampicillin, and erythromycin.
Robitussin DM may be used as an
antitussive.
Pneumonia is a risk for
any postoperative patient.
Pain, xerostomia, and dysphasia are or are not late complications of radiation therapy?
are NOT
Treatment of choice for _____ is penicillin.
bacterial pharyngitis
Early complications of tracheostomy tube management include
bleeding, pneumothorax, air embolism, aspiration, subcutaneous emphysema, recurrent laryngeal nerve damage, and posterior tracheal wall penetration.
To use CPAP, the patient must be
breathing independently.
How is cuff pressure monitored?
by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique.
Mixed sleep apnea is a combination of
central and obstructive apnea within one apneic episode.
Earlier symptoms of laryngeal cancer
complains of a persistent cough or sore throat and pain and burning in the throat, especially when consuming hot liquids or citrus juices.
Sibilant wheezes are
continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.
Sonorous wheezes are
deep, low-pitched rumbling sounds heard primarily during expiration.
Rhinorrhea refers to
drainage of a large amount of fluid from the nose.
Kyphoscoliosis is characterized by
elevation of the scapula and a corresponding S-shaped spine.
postoperative instructions after a laryngeal surgery: The nurse encourages the patient to cough how often and why?
every 2 hours to promote effective gas exchange.
Clinical manifestations associated with obstructive sleep apnea OSA include
excessive daytime sleepiness, insomnia, loud snoring, impotence, and arrhythmias.
Administration of low-flow nasal oxygen at night can help relieve hypoxemia in some patients but
has little effect on the frequency or severity of apnea.
Re the Pt with an endotracheal tube, Restraining the patient may be necessary because
he or she may attempt to remove or pull the tube.
Excess zinc can impair the immune system and lower the levels of
high-density lipoproteins {"good" cholesterol}. Therefore, long-term or ongoing use of zinc lozenges to prevent a cold is not recommended.
For a patient who has undergone surgery for a nasal obstruction, the nurse applies an
ice pack to reduce pain and swelling, not a warm pack.
Pulmonary embolism is associated with
immobility.
A total laryngectomy is performed
in most advanced stage IV laryngeal cancers.
Later symptoms of laryngeal cancer
include dysphagia, dyspnea, unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath.
Low cuff pressure can
increase the risk of aspiration pneumonia.
Clinical manifestations of hemorrhage related to carotid artery rupture include
increased pulse rate, decreased blood pressure, and rapid, deep respirations. The nurse monitors vital signs for these changes.
vital signs associated with hemorrhage
increased pulse rate, decreased blood pressure, rapid deep respirations, restlessness, and delayed capillary refill.
The priority nursing diagnosis is
ineffective airway clearance, utilizing the ABCs.
A pleural friction rub is heard secondary to
inflammation and loss of lubricating pleural fluid.
Enteral feedings are used 10 to 14 days after a laryngectomy to avoid
irritation to the sutures and reduce the risk of aspiration.
The nurse provides the patient and family with the following postoperative instructions: Water should not enter the stoma because
it will flow from the trachea to the lungs.
Complications occurring late following radiation therapy may include
laryngeal necrosis, edema, and fibrosis.
Late complications of radiation therapy include
laryngeal necrosis, edema, and fibrosis.
In a *partial laryngectomy*, a portion of the _____ is removed, along with one _____ and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing.
larynx; vocal cord
The carotid artery is at risk for hemorrhage because it
lies close to the stoma and may rupture from erosion if the wound does not heal properly.
postoperative instructions after a laryngeal surgery: wear a scarf over the stoma to
make the opening less obvious.
Obstructive sleep apnea occurs usually in what population?
men, especially those who are older and overweight.
For a patient who has undergone surgery for a nasal obstruction, it is important for the nurse to emphasize that
nasal packing will be in place postoperatively, necessitating mouth breathing.
Re the Pt with an endotracheal tube, The nurse does not suction the patient's
nose.
A barrel chest is seen in patients with emphysema as a result of
overinflation of the lungs.
Dehydration may lead to
poor wound healing and breakdown.
Imbalanced nutrition: less than body requirements, impaired verbal communication, and anxiety and depression are all
potential nursing diagnoses, but not the priority for the patient undergoing a laryngectomy.
BiPAP ventilation offers independent control of inspiratory and expiratory pressure while providing
pressure support ventilation.
When a patient undergoes a total laryngectomy, The laryngeal structures are
removed.
The nurse specifies standards of postoperative care for patients who have undergone a sinus surgery. The nurse observes the patient for
repeated swallowing. This helps detect possible hemorrhage.
Epistaxis is due to
rupture of tiny, distended vessels in the mucous membrane of any area of the nose.
Colorless and clear cerebrospinal fluid may drain from the nares in
severe nasal fractures.
To confirm the diagnosis of maxillary and frontal sinusitis and identify the pathogen,
sinus aspirates may be obtained.
Crackles are
soft, high-pitched, discontinuous popping sounds that occur during inspiration.
postoperative instructions after a laryngeal surgery: the nurse instructs the patient to avoid what athletic activity?
swimming
viruses responsible for acute pharyngitis include
the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus.
Lip speaking is available during
the immediate postoperative period.
CPAP is the most effective treatment for OSA because
the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep.
When a patient undergoes a total laryngectomy, there is permanent loss of
the voice.
A funnel chest occurs when...
there is a depression in the lower portion of the sternum.
When oral intake resumes after a laryngectomy, the nurse offers small amounts of
thick liquids.
Hemilaryngectomy is done by splitting the _____ of the larynx in the midline of the neck, and the portion of the _____ is removed with the tumor.
thyroid cartilage; vocal cord
Re the Pt with an endotracheal tube, Humidification is necessary
to keep the inspired air moist.
If allergies are present, the uvula will be
visibly edematous.