Ch 26: Upper Respiratory Problems

The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A, B, C, D].) a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage

ANS: A, B, D, C The patient should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the wound drain should be drained because the 200 mL of drainage will decrease the amount of suction in the wound drain and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting

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

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

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

A patient with a history of tonsillitis reports difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? a. Bilateral erythema of especially large tonsils b. Temperature 102.2°F, diaphoresis, and chills c. Contraction of neck muscles during inspiration d. β-hemolytic streptococcus in the throat culture

C Contraction of neck muscles during inspiration indicates that the patient is using accessory muscles for breathing and is in serious respiratory distress. The reddened and enlarged tonsils indicate pharyngitis. The increased temperature, diaphoresis, and chills indicate an infection, which could be β-hemolytic streptococcus or fungal infection, but not an emergency situation for the patient.

The nurse teaches a patient with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which statement, if made by the patient, indicates further teaching is required? a. "I should avoid using ibuprofen for pain and discomfort." b. "It is important for me to take my blood pressure medication every day." c. "I will sit down and pinch the tip of my nose for at least 10 to 15 minutes." d. "If I get a nosebleed, I will lie down flat and raise my feet above my heart."

D A simple measure to control epistaxis (or a nosebleed) is for the patient to remain quiet in a sitting position. Another measure is to apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes. Aspirin and nonsteroidal antiinflammatory drugs such as ibuprofen increase the bleeding time and should be avoided. Elevated blood pressure makes epistaxis more difficult to control. The patient should continue with antihypertensive medications as prescribed.

A patient is admitted for joint replacement surgery and has a permanent tracheostomy. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Suction the tracheostomy. b. Check stoma site for skin breakdown. c. Complete tracheostomy care using sterile technique. d. Provide oral care with a toothbrush and tonsil suction tube.

D Oral care (for a stable patient with a tracheostomy) can be delegated to UAP. A registered nurse would be responsible for assessments (e.g., checking the stoma for skin breakdown) and tracheostomy suctioning and care.

The best method for determining the risk of aspiration in a patient with a tracheostomy is to a. consult a speech therapist for swallowing assessment b. have the patient drink plain water and assess for coughing c. assess for change in sputum color 48 hours after patient drinks small amount of blue dye d. suction above the cuff after the patient eats or drinks to determine presence of food in trachea

A Rationale: The ability to swallow secretions without aspiration has traditionally been evaluated with the use of blue dye. Recent studies, however, do not support this test, and it is no longer recommended. Instead, clinical assessment by a speech therapist, videofluoroscopy, or fiberoptic endoscopic evaluations of swallow are recommended. Patients should begin swallowing with thickened liquids, not plain water. Ability to swallow should be assessed with the cuff deflated, because cuff inflation may interfere with swallowing ability.

When initially teaching a patient the supraglottic swallow after a radical neck dissection, with which food or fluid should the nurse begin? a. Cola b. Applesauce c. French fries d. White grape juice

A When learning the supraglottic swallow, it may be helpful to start with carbonated beverages because the effervescence provides clues about the liquid's position. Thin, watery fluids should be avoided because they are difficult to swallow and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce, decrease the risk of aspiration.

A school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus (select all that apply.)? a. Cover the nose when coughing. b. Obtain an influenza vaccination. c. Stay at home when symptomatic. d. Drink noncaffeinated fluids daily. e. Obtain antibiotic therapy promptly.

A, B, C Covering the nose and mouth when coughing is an effective way to prevent the spread of the virus. Obtaining an influenza vaccination helps prevent the flu. Staying at home helps prevent direct exposure of others to the virus. Drinking fluids helps liquefy secretions but does not prevent influenza. Antibiotic therapy is not used unless the patient develops a secondary bacterial infection.

When planning health care teaching to prevent or detect early head and neck cancer, which people would be the priority to target (select all that apply)? a. 65-year-old man who has used chewing tobacco most of his life b. 45-year-old rancher who uses snuff to stay awake while driving his herds of cattle c. 21-year-old college student who drinks beer on weekends with his fraternity brothers d. 78-year-old woman who has been drinking hard liquor since her husband died 15 years ago e. 22-year-old woman who has been diagnosed with human papilloma virus (HPV) of the cervix

A, B, D, E Rationale: Eighty five percent of head and neck cancers are caused by tobacco use. Excessive alcohol consumption is also a major risk factor. Head and neck cancers in people younger than 50 years of age have been associated with human papillomavirus (HPV) infection. Sun exposure is also a risk factor.

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

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

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

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

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

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

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

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.

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

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.

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

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

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

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

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

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.

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

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

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

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.

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when the tracheostomy tube is expelled by coughing. What is the priority action by the nurse? a. Suction the tracheostomy opening. b. Maintain the airway with a sterile hemostat. c. Use an Ambu bag and mask to ventilate the patient. d. Insert the tracheostomy tube obturator into the stoma.

B As long as the patient is not in acute respiratory distress after dislodging the tracheostomy tube, the nurse should use a sterile hemostat to maintain an open airway until a sterile tracheostomy tube can be reinserted into the tracheal opening. The tracheostomy is an open surgical wound that has not had time to mature into a stoma. If the patient is in respiratory distress, the nurse will use an Ambu bag and mask to ventilate the patient temporarily.

A patient has a tracheostomy tube after reconstructive surgery for invasive head and neck cancer. What is most important for the nurse to assess before performing tracheostomy cannula care? a. Level of consciousness b. Quality of breath sounds c. Presence of the gag reflex d. Tracheostomy cuff pressure

B Before performing tracheostomy care, the nurse will auscultate lung sounds to determine the presence of secretions. To prevent aspiration, secretions must be cleared either by coughing or by suctioning before performing tracheostomy cannula care.

Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? a. Assessing the need for suctioning b. Suctioning the patient's oropharynx c. Assessing the patient's swallowing ability d. Maintaining appropriate cuff inflation pressure

B Providing the individual has been trained in correct technique, the UAP may suction the patient's oropharynx. Whereas assessing the need for suctioning should be performed by an RN or licensed practical nurse, swallowing assessment and the maintenance of cuff inflation pressure should be performed solely by the RN.

When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment? a. Patient comfort b. Airway patency c. Incisional drainage d. Blood pressure and heart rate

B Remember the ABCs with prioritization. Airway patency is always the highest priority and is essential for a patient undergoing surgery surrounding the upper respiratory system. Comfort, drainage, and vital signs follow the ABCs in priority.

The nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to an employee. Which question should the nurse ask before administration of this vaccine? a. "Are you allergic to chicken?" b. "Could you be pregnant now?" c. "Did you ever have influenza?" d. "Have you ever had hepatitis B?"

B The live attenuated influenza vaccine (LAIV) is given by nasal spray and approved for healthy people age 2 to 49 years. The LAIV is given only to nonpregnant, healthy people. The inactivated vaccine is given by injection and is approved for use in people 6 months or older. The inactivated vaccine can be used in pregnancy, in people with chronic conditions, or in people who are immunosuppressed. Influenza vaccination is contraindicated if the person has a history of Guillain-Barré syndrome or a hypersensitivity to eggs.

Appropriate discharge teaching for the patient with a permanent tracheostomy after a total laryngectomy for cancer would include (select all that apply) a. encouraging regular exercise such as swimming b. washing around the stoma daily with a moist washcloth c. encouraging participation in postlaryngectomy support group d. providing pictures and "hands-on" instruction for tracheostomy care e. teaching how to hold breath and trying to gag to promote swallowing reflex

B, C, D Rationale: Although regular exercise is important, such as walking and shoulder and arm exercises, swimming is contraindicated. The nurse would instruct the patient NOT to swim, as water entering the laryngeal stoma would risk choking and aspiration. All of the other activities identified (including cleaning around the stoma daily with a damp, moist washcloth, providing pictures and "hands-on" time to practice for tracheostomy care, and encouraging the patient to join a support group with other laryngectomees) are appropriate.

A patient is being discharged from the emergency department after being treated for epistaxis. In teaching first aid measures in the event the epistaxis would recur, what measures should the nurse suggest (select all that apply.)? a. Tilt patient's head backwards. b. Apply ice compresses to the nose. c. Tilt head forward while lying down. d. Pinch the entire soft lower portion of the nose. e. Partially insert a small gauze pad into the bleeding nostril.

B, D, E First aid measures to control epistaxis include placing the patient in a sitting position, leaning forward. Pinching the soft lower portion of the nose or inserting a small gauze pad into the bleeding nostril should stop the bleeding within 15 minutes. Tilting the head back or forward does not stop the bleeding but rather allows the blood to enter the nasopharynx, which could result in aspiration or nausea or vomiting from swallowing blood. Lying down also will not decrease the bleeding.

Which nursing action would be of highest priority when suctioning a patient with a tracheostomy? a. Auscultating lung sounds after suctioning is complete b. Providing a means of communication for the patient during the procedure c. Assessing the patient's oxygenation saturation before, during, and after suctioning d. Administering pain and/or antianxiety medication 30 minutes before suctioning

C Rationale: A patient with a tracheostomy is at risk for hypoxemia during and after suctioning. Patients should always be pre-oxygenated with 100% FIO2 prior to suctioning. In addition, it is imperative to monitor the patient's O2 status before, during, and after suctioning.

The nurse is caring for a patient with a tracheostomy. What is the priority nursing assessment for this patient? a. Electrolyte levels and daily weights b. Assessment of speech and swallowing c. Respiratory rate and oxygen saturation d. Pain assessment and assessment of mobility

C The priority assessment in the care of a patient with a tracheostomy focuses on airway and breathing. These assessments supersede the nurse's assessments that may also be necessary, such as nutritional status, speech, pain, and swallowing ability.

A patient is seen at the clinic with fever, muscle aches, sore throat with yellowish exudate, and headache. The nurse anticipates that the interprofessional management will include (select all that apply) a. antiviral agents to treat influenza b. treatment with antibiotics starting ASAP c. a throat culture or rapid strep antigen test d. supportive care, including cool, bland liquids e. comprehensive history to determine possible etiology

C, D, E Rationale: The goals of nursing management are infection control, symptom relief, and prevention of secondary complications. Drugs are not prescribed until the etiology is known. Unnecessary use of antibiotics leads to the development of antibiotic-resistant organisms. A thorough history and a throat culture help identify the cause. The nurse should encourage the patient with pharyngitis to increase fluid intake. Cool, bland liquids and gelatin do not irritate the pharynx; citrus juices are often irritating.

The nurse teaches a patient about the use of budesonide intranasal spray for seasonal allergic rhinitis. The nurse determines that medication teaching is successful if the patient makes which statement? a. "My liver function will be checked with blood tests every 2 to 3 months." b. "The medication will decrease the congestion within 3 to 5 minutes after use." c. "I may develop a serious infection because the medication reduces my immunity." d. "I will use the medication every day of the season whether I have symptoms or not."

D Budesonide should be started 2 weeks before pollen season starts and used on a regular basis, not as needed. The spray acts to decrease inflammation and the effect is not immediate as with decongestant sprays. At recommended doses, budesonide has only local effects and will not result in immunosuppression or a systemic infection. Zafirlukast (Accolate) is a leukotriene receptor antagonist and may alter liver function tests (LFTs). LFTs must be monitored periodically in the patient taking zafirlukast.

A patient with allergic rhinitis reports severe nasal congestion; sneezing; and watery, itchy eyes and nose at various times of the year. To teach the patient to control these symptoms, the nurse advises the patient to a. avoid all intranasal sprays and oral antihistamines b. limit the usage of nasal decongestant spray to 10 days c. use oral decongestants at bedtime to prevent symptoms during the night d. keep a diary of when the allergic reaction occurs and what precipitates it

D Rationale: An important intervention involves identifying and avoiding triggers of allergic reactions. The nurse should instruct the patient to keep a diary of times when the allergic reaction occurs and of the activities that precipitate the reaction.

While in the recovery room, a patient with a total laryngectomy is suctioned and has bloody mucus with some clots. Which nursing interventions would apply? a. Notify the physician immediately b. Place the patient in the prone position to facilitate drainage c. Instill 3 mL of normal saline into the tracheostomy tube to loosen secretions d. Continue your assessment of the patient, including O2 saturation, respiratory rate, and breath sounds

D Rationale: Immediately after surgery, the patient with a laryngectomy requires frequent suctioning by means of the laryngectomy tube. Secretions typically change in amount and consistency over time. Secretions may initially be blood-tinged and then diminish in amount and become less bloody over time. Normal saline through the tracheostomy tube is not recommended to assist with removal of thickened secretions because it causes hypoxia and may contribute to the development of ventilator-associated pneumonia (VAP).

A patient was seen in the clinic for an episode of epistaxis, which was controlled by placement of anterior nasal packing. During discharge teaching, the nurse instructs the patient to a. use aspirin for pain relief b. remove the packing later that day c. skip the next dose of antihypertensive medication d. avoid vigorous nose blowing and strenuous activity

D Rationale: The nurse should teach the patient about home care before discharge: to avoid vigorous nose blowing, strenuous activity, lifting, and straining for 4 to 6 weeks; to sneeze with the mouth open; and to avoid the use of aspirin-containing products or nonsteroidal antiinflammatory drugs (NSAIDs).

The patient seeks relief from the symptoms of an upper respiratory infection (URI) lasting for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis? a. Coughing b. Fever, chills c. Dust allergy d. Maxillary pain

D The nurse should assess the patient for sinus pain or pressure as a clinical indicator of acute sinusitis. Coughing and fever are nonspecific clinical indicators of a URI. A history of an allergy that is likely to affect the upper respiratory tract is supportive of the sinusitis diagnosis but is not specific for sinusitis.

The patient has decided to use the voice rehabilitation that offers the best speech quality even though it must be cleaned regularly. The nurse knows that this is what kind of voice rehabilitation? a. Electromyography b. Intraoral electrolarynx c. Neck type electrolarynx d. Transesophageal puncture

D The transesophageal puncture provides a fistula between the esophagus and trachea with a one-way valved prosthesis to prevent aspiration from the esophagus to the trachea. Air moves from the lungs and vibrates against the esophagus, and words are formed with the tongue and lips as the air moves out the mouth. The electromyography and both electrolarynx methods produce low-pitched mechanical sounds.

The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident? a. Hypersensitivity to eggs b. Age older than 80 years c. History of upper respiratory infections d. Chronic obstructive pulmonary disease (COPD)

A Although current vaccines are highly purified and reactions are extremely uncommon, a hypersensitivity to eggs precludes vaccination because the vaccine is produced in eggs. Advanced age and a history of respiratory illness are not contraindications for influenza vaccination.

The nurse observes clear nasal drainage in a patient newly admitted with facial trauma with a nasal fracture. What is the nurse's priority action? a. Test the drainage for the presence of glucose. b. Suction the nose to maintain airway clearance. c. Document the findings and continue monitoring. d. Apply a drip pad and reassure the patient this is normal.

A Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF. Suctioning should not be done. Documenting the findings and monitoring are important after notifying the health care provider. A drip pad may be applied, but the patient should not be reassured that this is normal.

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

A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement? a. Apply an external splint to the nose. b. Insert plastic nasal implant surgically. c. Humidify the air for mouth breathing. d. Maintain surgical packing in the nose.

D A goal that is common to nursing and medical management of a patient after rhinoplasty is to prevent the formation of a septal hematoma and potential infections resulting from a septal hematoma. Therefore, the nurse helps to keep the nasal packing in the nose. The packing applies direct pressure to oozing blood vessels to stop postoperative bleeding. A medical goal includes realigning the fracture with an external or internal splint. The nurse helps maintain the airway by humidifying inspired air because the nose is unable to do so following surgery because it is swollen and packed with gauze.

The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect to teach the patient about? a. Nasal packing b. Epistaxis balloon c. Gastrostomy tube d. Peripheral skin care

C Because 50% of patients with head and neck cancer are malnourished before treatment begins, many patients need enteral feeding via a gastrostomy tube because the effects of treatment make it difficult to take in enough nutrients orally, whether surgery, chemotherapy, or radiation is used. Nasal packing could be used with epistaxis or with nasal or sinus problems. Peripheral skin care would not be expected because it is not related to head and neck cancer.