Chapter 18: Management of Patients with Upper Respiratory Tract Disorders

The nurse assesses a client who has a nasogastric tube for long-term nutritional needs for complications associated with the medical device.

purulant nasal drainage rhinosinusitis

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

swimming

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 client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis?

Apply direct continuous pressure.

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

Continuous positive airway pressure (CPAP

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 reports periodic sneezing, runny nose, and itchy eyes throughout the year. Which instruction(s) will the nurse include when teaching the client about these signs and symptoms? Select all that apply.

"Avoid powders and scented products." "Stay away from all tobacco smoke." "Blow the nose before using a nasal spray." "Clean the nasal spray container after each use."

A client seeks care for hoarseness that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question?

"Do you smoke cigarettes, cigars, or a pipe?"

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."

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of

2 to 12 days

Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)?

Amoxicillin

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 who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

Develop an alternate method of communication.

You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis?

Encourage deep breathing every 2 hours.

A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for:

Fever

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

The nurse makes the observations shown in the accompanying notes about a client who will be discharged following a laryngectomy. The nurse makes a referral to the home health nurse for client reteaching based on which observation?

Initial washing of hands after cleaning inner cannula.

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.

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

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

The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect?

edema of the upper airway

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

impaired verbal communication

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