EAQ- Lewis Med Surg CH.27, Nursing Management: Upper Respiratory Problems- Problems of Pharynx, Trachea, and Larynx

The nurse is observing a new graduate nurse during suctioning of a tracheostomy patient. Which action by the graduate nurse would require intervention? 1. Applying suction while inserting the catheter. 2. Limiting the suction time to 10 seconds or less. 3. Assessing the patient's SpO2 and heart rate and rhythm before the procedure. 4. Providing preoxygenation for a minimum of 30 seconds before the procedure.

1. Applying suction while inserting the catheter. Suction is not applied while inserting the catheter; intermittent suction is applied as the catheter is being withdrawn. Preoxygenation is also required before suctioning, and suction time should be limited to 10 seconds or less. A patient is at risk for hypoxemia after suctioning. Therefore it is imperative to monitor the patient's oxygen status before, during, and after suctioning. The catheter should be rotated during withdrawal.

The patient with a tracheostomy is using a speaking valve and begins having shortness of breath. What action by the nurse is most appropriate? 1. Remove the speaking valve immediately 2. Call the attending health care provider 3. Deflate the tracheostomy cuff 4. Page the speech therapist

1. Remove the speaking valve immediately Initially, a patient may be able to tolerate only short periods of use until he or she becomes acclimated to exhaling through the mouth. However, during or even after any period of acclimation if the patient demonstrates any signs of respiratory distress, the priority will be to remove the valve or cap immediately. Calling the attending health care provider will create a delay and should be done after the speaking valve is removed. The cuff would be deflated already and in the setting of respiratory distress; the cuff should be inflated after the speaking valve is removed. Removing the speaking valve because of respiratory distress should not be delayed. Communication of adverse events can be communicated to the appropriate care parties after the immediate life-threatening event has been addressed.

Which tube has openings on the surface of the cannula to permit airflow? 1. Speaking tracheostomy tube 2. Fenestrated tracheostomy tube 3. Tracheostomy tube with foam-filled cuff 4. Tracheostomy tube with cuff and pilot balloon

2. Fenestrated tracheostomy tube A fenestrated tube has openings on the surface of the outer cannula that permit air to flow over the vocal cords. Speaking tracheostomy tubes, tracheostomy tubes with foam-filled cuffs, and tracheostomy tubes with cuffs and pilot balloons do not have openings on the surface of the cannula.

The nurse is suctioning the patient's tracheostomy. Which occurrence is the first priority consideration by the nurse? 1. Heart rate increases from a baseline of 65 to 70 2. Heart rate decreases from a baseline of 65 to 44 3. SpO2 decreases from 100% to 92% 4. SpO2 decreases from 99% to 90%

2. Heart rate decreases from a baseline of 65 to 44 A heart rate decrease by 20 or more beats from baseline is an indication to immediately discontinue suctioning through the tracheostomy. A heart rate increase from baseline by 40 or more beats is an indication to immediately discontinue suctioning through the tracheostomy. The heart rate only increases by 5 beats and is not a reason, by itself, to discontinue suctioning. A decrease in SpO2 less than 90% is an indication to discontinue suctioning through the tracheostomy.

Which statement by the student nurse indicates a need for further instruction about airway obstruction? 1. "Airway obstruction can be either partial or complete." 2. "Endotracheal intubation may be performed to reestablish the airway." 3. "Ventilation should be provided after 10 minutes of complete airway obstruction." 4. "Airway obstruction may be caused by aspiration of food contents into the windpipe."

3. "Ventilation should be provided after 10 minutes of complete airway obstruction." Complete airway obstruction should be corrected within three to five minutes, because delaying can lead to permanent brain damage or death. Airway obstruction can be either partial or complete. Establishing ventilation can be performed by endotracheal intubation, tracheostomy, or cricothyroidotomy. Airway obstruction can be caused by aspiration of food contents into the windpipe, allergic reactions, malignancies, and trauma.

A speech therapist needs to determine if a patient can have a fenestrated tracheostomy tube. What aspect is most important to assess? 1. Adequate pulse oximetry 2. Bilaterally clear lung sounds 3. Ability to swallow without aspiration 4. In the process of being weaned from mechanical ventilation

3. Ability to swallow without aspiration Before a fenestrated tube can be applied, make sure the patient can swallow adequately to prevent aspiration. Pulse oximetry within normal limits and clear lung sounds would not affect whether a fenestrated tracheostomy tube was used. Also, the patient must be able to breathe spontaneously for a fenestrated tracheostomy tube to be inserted.

Which instructions should the nurse include when teaching self-care to a patient with acute pharyngitis? Select all that apply. 1. Drink citrus juices. 2. Restrict fluid intake. 3. Gargle with warm salt water. 4. Suck on popsicles or hard candies. 5. Use a cool-mist vaporizer or humidifier.

3. Gargle with warm salt water. 4. Suck on popsicles or hard candies. 5. Use a cool-mist vaporizer or humidifier. Symptom relief is a major goal of nursing management in a patient with acute pharyngitis. The nurse should instruct the patient to gargle with warm salt water, suck on popsicles or hard candies, and use a cool-mist vaporizer or humidifier. Citrus juices can irritate the throat and should not be recommended. The patient should increase fluid intake to keep the secretions thin so they can be easily expectorated.

Which action by the student nurse when providing tracheostomy care to a patient indicates a need for further teaching? 1. Performs hand hygiene when indicated 2. Positions the patient in a semi-Fowler's position 3. Removes dried secretions from the stoma using gauze that is soaked with alcohol 4. Suctions the patient as needed because the patient is unable to cough up secretions

3. Removes dried secretions from the stoma using gauze that is soaked with alcohol Dried secretions from the stoma are removed using gauze that is soaked in sterile water or normal saline, but not in alcohol. Hand hygiene reduces the risk of infection to the patient. Tracheostomy care is performed by positioning the patient in a semi-Fowler's position. The nurse can suction as needed when the patient is unable to cough up the thick and hard secretions.

Which information should a nurse provide to the family of a patient who is using an endotracheal tube in an emergency department? 1. "The tube allows for patient movement." 2. "The patient can eat with an endotracheal tube." 3. "An endotracheal tube is used to aspirate the trachea of the patient." 4. "An endotracheal tube is used to manage proper ventilation initially."

4. "An endotracheal tube is used to manage proper ventilation initially." Patients requiring mechanical ventilation are initially managed with an endotracheal tube. The tube does not allow for much movement and patients who have endotracheal tubes cannot eat. Endotracheal intubation is generally not performed to aspirate the trachea of a patient.

Which disease is associated with scratchy throat, severe pain, and enlargement of the anterior cervical lymph node? 1. Sinusitis 2. Influenza 3. Allergic rhinitis 4. Acute pharyngitis

4. Acute pharyngitis Acute pharyngitis is an inflammation of the pharynx and enlargement of the anterior cervical lymph node. Sore throat, scratchiness in the throat, and difficulty swallowing are clinical manifestations of acute pharyngitis. Sinusitis is inflammation of the sinuses. It develops when inflammation or hypertrophy of the mucosa blocks the openings in the sinuses through which mucus drains into the nose. This causes pain over the affected sinus, purulent nasal drainage, nasal obstruction, congestion, fever, and malaise. Influenza is an infectious disease caused by the influenza virus. The systemic symptoms of influenza include chills, fever, anorexia, malaise, and generalized myalgia. Allergic rhinitis is an allergic inflammation of the nasal airways. It includes sneezing; watery, itchy eyes; altered sense of smell; and thin, watery nasal discharge resulting in sustained mucus production and nasal congestion.

Which nursing intervention should the nurse include in the teaching plan for a patient with acute pharyngitis whose laboratory reports indicate the presence of a candidiasis infection? 1. Encourage the patient to avoid aspirin. 2. Encourage the patient to drink lemon juice. 3. Encourage the patient to only drink hot tea. 4. Encourage the patient to gargle with warm salt water.

4. Encourage the patient to gargle with warm salt water. Gargling with warm salt water helps in relieving swelling and discomfort in the throat. The patient may have aspirin or ibuprofen if he or she reports pain. Lemon is a citrus fruit and would result in more throat irritation. Warm and cool fluids are appropriate for patients with pharyngitis related to candida.

The nurse is completing tracheostomy care. Which of these is the best method for ensuring the fit of tracheostomy ties? 1. Have the respiratory therapist check the ties. 2. Ask the patient if the ties feel comfortable after tying them. 3. Place one finger underneath the ties to ensure they are not too tight around the neck. 4. Place two fingers underneath the ties to ensure they are not too tight around the neck.

4. Place two fingers underneath the ties to ensure they are not too tight around the neck. When securing tracheostomy ties, place two fingers underneath the ties to ensure that they are not too tight around the patient's neck. The respiratory therapist may not be trained in changing the ties, or may not check them accurately. The patient may not be able to identify if the ties are too tight. One finger beneath the tie is too tight.