Chapter 29 - Noninfectious Upper Respiratory Problems

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first?

Initiate Standard Precautions. The nurse should implement Standard Precautions and don gloves prior to completing the other actions.

The nurse is planning care for the non-English-speaking client who is on complete voice rest. What alternative method of communication does the nurse implement?

Picture board A picture board overcomes language barriers and can be used to communicate with clients who do not speak English well if a translator or a translation phone is not readily available.

What is the purpose of wearing fluoride gel trays during radiation therapy of the mouth?

Prevent radiation scatter when the beam hits metal in the mouth The gel trays help prevent radiation scatter when the beam hits metal in the mouth. They will not provide additional moisture to the mouth.

Which clinical manifestation in the client with facial trauma is the nurse's first priority?

Stridor Stridor is an indication of a partial airway obstruction and requires immediate attention. Although bleeding is important in all trauma clients, it is not the first priority in assessing the "ABCs".

A new client arrives in the medical-surgical unit with a flap after a total laryngectomy. The flap appears dusky in color. What is the nurse's first action?

Use a Doppler device to assess flow to the area. A complete assessment of the area, including Doppler activity of major feeding vessels, needs to be completed and the surgeon must be notified, because the client may have to be returned to the operating room immediately. Neither hot nor cold packs nor dressings (nor anything, for that matter) should be applied to the flap site.

A client has received packing for a posterior nosebleed. In reviewing the client's orders, which order does the nurse question?

"Give ibuprofen 800 mg every 8 hours as needed for pain." Ibuprofen is contraindicated in a client with a nosebleed because nonsteroidal anti-inflammatory drugs inhibit clotting.

A client admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response?

"Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe." During sleep, the muscles relax and the tongue and neck structures are displaced with the tongue falling back, causing an upper airway obstruction. This obstruction leads to apnea and increased levels of carbon dioxide. Respiratory acidosis stimulates neural centers in the brain, and the client awakens, takes a deep breath, and goes back to sleep.

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.)

- A 24-year-old with a traumatic brain injury - A 58-year-old at risk for aspiration following radiation therapy - A 66-year-old who is a quadriplegic and has a sacral ulcer - An 80-year-old who is aphasic after a cerebral vascular accident Risk for asphyxiation related to inspissated oral and nasopharyngeal secretions is caused by poor oral hygiene. Clients at risk include those with altered mental status and level of consciousness (traumatic brain injury), dehydration, an inability to communicate (aphasic) and cough effectively (quadriplegic), and a risk of aspiration (aspiration precautions). The client with a fractured femur is at risk for a pulmonary embolism.

Which statement by a client with a laryngectomy indicates a need for further discharge teaching?

"I can't put anything over my stoma to cover it." Loose clothing or a covering such as a scarf can be used to cover the stoma if the client desires. To avoid aspiration, the client with a laryngectomy should not swim.

A client is scheduled for a total laryngectomy. Which statement by the client indicates the need for further teaching about the procedure?

"I will have to take special care not to aspirate while eating." Aspiration cannot occur after a total laryngectomy because the airway is completely separated from the esophagus. The client will not be able to breathe through the nose.

A client's mother asks what is the most important thing she will need to know to care for her son, who is having an inner maxillary fixation completed as an outpatient. What does the nurse tell her?

"Make sure he always has wire cutters with him." It is extremely important that the client always have wire cutters in the event of emesis, so the wires can be cut to prevent aspiration. Remind the client to contact the surgeon as soon as possible if the wires have been cut, so that fixation can be re-established.

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this client's teaching?

"Make sure you clean the humidifier to prevent infection." Priority teaching related to the use of a room humidifier focuses on infection control. Clients should be taught to meticulously clean the humidifier to prevent the spread of mold or other sources of infection.

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond?

"This is normal after surgery. What types of food do you like to eat?" Many clients experience changes in taste after surgery. The nurse should identify foods that the client wants to eat to ensure the client maintains necessary nutrition

A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, "How will this medication help me?" How should the nurse respond?

"This medication will promote daytime wakefulness." Modafinil is helpful for clients who have narcolepsy (uncontrollable daytime sleep) related to sleep apnea. This medication promotes daytime wakefulness.

After teaching a client who is prescribed "voice rest" therapy for vocal cord polyps, a nurse assesses the client's understanding. Which statement indicates the client needs further teaching?

"When I speak, I will whisper rather than use a normal tone of voice." Treatment for vocal cord polyps includes no speaking, no lifting, and no smoking. The client has to be educated not to even whisper when resting the voice. It is also appropriate for the client to stay out of rooms where people are smoking, to stay hydrated, and to use stool softeners.

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.)

- Observe for clear drainage. - Assess for signs of bleeding. - Watch the client for frequent swallowing. - Ask the client to open his or her mouth. The nurse should observe for clear drainage because of the risk for cerebrospinal fluid leakage. The nurse should assess for signs of bleeding by asking the client to open his or her mouth and observing the back of the throat for bleeding. The nurse should also note whether the client is swallowing frequently because this could indicate postnasal bleeding.

A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this client's teaching? (Select all that apply.)

- You will need to cut the wires if you start vomiting. - Eat six soft or liquid meals each day while recovering - Irrigate your mouth every 2 hours to prevent infection - Sleep in a semi-Fowler's position after the surgery The client needs to know how to cut the wires in case of emergency. If the client vomits, he or she may aspirate. The client should also be taught to eat soft or liquid meals multiple times a day, irrigate the mouth with a Waterpik to prevent infection, and sleep in a semi-Fowler's position to assist in avoiding aspiration.

A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.)

A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago An 88-year-old with esophageal cancer who is awaiting gastric tube placement The nurse can delegate stable clients to the LPN. The client who had a biopsy 2 days ago and the client who is awaiting gastric tube placement are stable.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?

A 55-year-old woman who is 50 pounds overweight The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.

A client with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which preoperative intervention can be accomplished by an LPN/LVN working on the unit?

Administering preoperative antibiotics and anxiolytics Administering medication is a skill within the LPN/LVN scope of practice. As a reminder, anxiolytics must be administered after the operative consent has been signed, or the consent will be invalid.

A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?

Airway patency A patent airway is the priority. The nurse first should make sure that the airway is patent and then should determine whether the client is in pain and whether bone displacement or blood loss has occurred.

Which two factors in combination are the greatest risk factors for head and neck cancer?

Alcohol and tobacco use The combination of alcohol and tobacco use is one of the greatest risk factors for head and neck cancer.

A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first?

Ask the client if he or she has ever been evaluated for sleep apnea. Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment.

A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first?

Ask the client to gargle with mouthwash containing lidocaine. Mouthwashes and throat sprays containing a local anesthetic agent such as lidocaine or diphenhydramine can provide relief from a sore throat after radiation therapy. Intravenous pain medications may be used if local anesthetics are unsuccessful.

A client with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first?

Ask the client whether CPAP has been used consistently at night. The nurse should assess whether the client has actually consistently been using CPAP at night, because clients may have difficulty with the initial adjustment to this therapy.

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery?

Assist the client to choose a communication method. The client will not be able to speak after surgery. The nurse should assist the client to choose a communication method that he or she would like to use after surgery. Assessing the client's airway and administering IV pain medication are done after the procedure.

A newly hired RN with no previous emergency department (ED) experience has just completed a 1-month orientation. Which of these clients would be most appropriate to assign to this nurse?

Client on warfarin (Coumadin) with epistaxis with profuse bleeding The initial treatment for epistaxis is upright positioning with direct lateral pressure to the nose. A nurse with minimal ED experience could be expected to safely provide care for this client. In addition, laboratory work should be obtained to assess the client's ability to clot, given that the client is on warfarin (Coumadin).

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?

Collect the nasal drainage on a piece of filter paper. The client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?

Contact the provider and prepare for intubation. Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and restlessness, should be immediately intubated to ensure airway patency

The nursing assistant has taken vital signs of the ventilated postoperative client who has had radical neck surgery. What does the nurse tell the assistant to be especially vigilant for?

Continuous oozing of bright-red blood Bright-red blood indicates a rupture in the carotid artery and requires immediate attention.

An emergency nurse is preparing to care for a client arriving by ambulance after a motor vehicle crash. The client has severe facial and neck injuries and emergency airway measures have been taken. Which type of airway does the nurse prepare for?

Cricothyroidotomy Cricothyroidotomy is an emergency procedure performed by emergency medical personnel to hold an airway open until a tracheotomy may be performed.

The client is a woman with severe angioedema and tongue swelling from exposure to seafood. She has stridor, and her oxygen saturation is 70%. For which type of respiratory support does the nurse prepare?

Cricothyroidotomy Rationale: Stridor is a sound made from a laryngeal obstruction, not just an oral obstruction. The fact that her oxygen saturation is so low indicates that this is a critical emergence and that her airway is going to become completely obstructed very soon.

The nurse answers a client's call light and realizes that the client has an upper airway obstruction. What is the nurse's first action?

Determine the cause of the obstruction. The first step the nurse should take is to determine the cause of the obstruction. After the cause has been determined (e.g., tongue, food, inflammation), the nurse can decide the next course of action. The obstruction cannot be removed until its origin has been determined.

The standard laryngectomy plan of care for a client admitted with laryngeal cancer includes these interventions. Which intervention will be most important for the nurse to accomplish before the surgery?

Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. In the immediate postoperative period, relieving pain and anxiety is going to be a major priority. Because the client will be unable to communicate verbally, establishing a way to communicate before the surgery will help by having a plan in place.

The nurse is assessing a client who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse?

Excessive swallowing Excessive swallowing in a client who has undergone a nasoseptoplasty may indicate posterior nasal bleeding and requires immediate attention.

A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration?

Tuck the chin down when swallowing. The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration.

A nurse assesses a client who has developed epistaxis. Which conditions in the client's history should the nurse identify as potential contributors to this problem? (Select all that apply.)

Hypertension Leukemia Cocaine use Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures.

A client is 1 day postoperative from a total laryngectomy for cancer. He has indicated to the nurse that he is experiencing pain. Pain management for him is best achieved with which medication?

IV morphine sulfate (Morphine) Morphine or other opioids are the best choice for this client in the immediate postoperative period. They can be given both as a bolus dose and continuously by patient-controlled analgesia. The client's airway and respiratory status must be carefully observed.

Which precaution is most important for the nurse to teach a client, who is a secretary and just had nasal tubes removed after a posterior nasal bleed?

If bleeding recurs, call 911 immediately. Rationale: The most important of all these precautions is to get emergency treatment as soon as any rebleeding occurs. The tissue is fragile and could rebleed easily and excessively. It is important for the client to avoid the issues that could lead to bleeding, such as nose blowing and the use of NSAIDs, but it is more important to stop the bleeding as soon as possible

A client who has fallen off a roof arrives in the emergency department with possible head, neck, and chest trauma. All of these health care provider requests are received. Which action will the nurse take first?

Immobilize the neck with a cervical collar. If the cervical spine has not already been stabilized by emergency medical services, this is the nurse's top priority. The neck should be held in place manually until a properly fitted cervical collar can be applied.

A client who has had a recent laryngectomy continues to report pain. Which medication would be best used as an adjunct to a narcotic once the client can take oral nutrition?

Liquid nonsteroidal anti-inflammatory drugs (NSAIDs) NSAIDs are an excellent adjunct when used with narcotics or opioid analgesia.

A client has been diagnosed with oral and laryngeal cancer. He completed a course of radiation, and it is 2 days since he underwent a total laryngectomy. The client had been very anxious about his surgery. Which medications does the nurse expect to find on his home medication list?

Lorazepam (Ativan) Lorazepam is a short-acting antianxiety medication that would be the most appropriate choice for this client.

A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first?

Make sure the string is taped to the client's cheek. The string should be attached to the client's cheek to hold the packing in place. The nurse needs to make sure that this does not move because it can occlude the client's airway.

The 62-year-old client whose brother was just diagnosed with head and neck cancer asks the nurse what he could do to reduce his risk for also developing this cancer. What is the nurse's best response?

Stop smoking and drink alcohol only in moderation The two most important risk factors for head and neck cancer are tobacco and alcohol use, especially in combination. Other risk factors include chronic laryngitis, exposure to chemicals, dusts, poor oral hygiene, long-term or severe gastroesophageal reflux disease, and oral infection with the human papillomavirus.

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.)

Stridor Ecchymosis behind the ear Stridor is a sign of airway obstruction and requires immediate intervention

Which clinical manifestation requires immediate action by the nurse for a client with laryngeal trauma?

Tachypnea Tachypnea is a sign of respiratory distress that may accompany laryngeal trauma; this requires immediate action on the part of the nurse.

The nurse manager at a long-term-care facility is planning care for a client who is receiving radiation therapy for laryngeal cancer. Which of these tasks will be best to delegate to a nursing assistant?

Washing the skin with soap and water Personal hygiene is within the scope of practice of the nursing assistant.