Brunner Med-surg ch 22 respiratory. Prep-u
A client is being discharged from an outpatient surgery center following a tonsillectomy. The nurse gives the following instructions:
"Gargle with a warm salt solution."
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
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."
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?
"I was chewing ice chips all day long."
A college student presents to the health clinical with signs and symptoms of viral rhinitis (common cold). The patient states, "I've felt terrible all week; what can I do to feel better?" Which of the following is the best response the nurse can give?
"You should rest, increase your fluids, and take Ibuprofen."
A 72-year-old male client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. If laryngeal cancer is suspected, the nurse would be most likely to hear which of the following complaints from the client?
A feeling of swelling at the back of the throat
Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?
Continuous positive airway pressure (CPAP)
You are caring for a client who is 42 years old and status post adenoidectomy. You find the client in respiratory distress when you enter his room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect?
Edema of the upper airway
A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is considered an early clinical indicator.
Hoarseness of more than 2 week's duration
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 young adult client has had a tonsillectomy and is in the immediate postoperative period. To make the client comfortable, the nurse intervenes by
Placing the client prone with the head turned to the side
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 1 to 10.
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 42-year-old female client is scheduled for endotracheal intubation prior to her surgery. Which of the following can the nurse instruct this client?
The ET tube will maintain your airway while you're under anesthesia.
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
Total laryngectomy
The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed?
When the patient has less than 30 mL for 2 consecutive days
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of
2 to12 days
Which of the following postoperative instructions does a nurse provide a patient and family to avoid after a laryngeal surgery?
Swimming
Select the nursing diagnosis that would warrant immediate health care provider notification
Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation
A 62-year-old male client with a history of chronic laryngitis arrives at the clinic complaining of a hoarseness "he can't shake." The nurse is aware that this client may be at risk for which of the following conditions?
Laryngeal cancer
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
A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to
Seek medical help if he experiences inability to swallow
Which assessment finding puts a client at increased risk for epistaxis?
cocaine use
Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require?
emotional support
You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
noisy breathing
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:
A permanent tracheal stoma would be necessary.
The antibiotic of choice utilized in the treatment of acute bacterial rhinosinusitis (ABRS) includes which of the following?
Amoxicillin (Augmentin)
A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection?
An antiviral agent such as acyclovir
The nurse is caring for a patient admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been completed. Which of the following interventions should the nurse include in the patient's care?
Apply an ice pack
A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis?
Apply direct continuous pressure.
The nurse is providing discharge instructions to a patient following nasal surgery who has nasal packing. Which of the following discharge instructions would be most appropriate for the patient?
Avoid sports activities for 6 weeks
