EXAM 3 Ch 22 up to date 2

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." Explanation: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea.

An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by periods of breathing cessation for:

10 seconds with 5 episodes/hour OSA is characterized by frequent and loud snoring, with breathing cessation for 10 seconds or longer, for at least five episodes per hour, followed by abrupt awakening with a loud snort as the blood oxygen level drops. Symptoms typically progress with weight gain, aging, and during the transition to menopause for women.

The client is to receive cephalexin (Ancef) 500 mg in 50 mL of normal saline intravenous piggyback. The medication is to infuse over 30 minutes. How many mL/hr would the nurse set the intravenous pump? Enter the correct number ONLY.

100 The volume of the IV medication is 50 mL. The time for infusion is 30 minutes or 0.5 hr. 50 mL/0.5 hr = 100 mL/1 hr.

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

2 to 12 days Explanation: HSV-1 is transmitted primarily by direct contact with infected secretions. The incubation period is about 2 to 12 days. The time periods of 20 to 30 days, 1 to 3 months, and 3 to 6 months exceed the incubation period.

35. The nurse is caring for a client who has recurrent sinusitis. Which consideration could nurse suggest to best decrease the frequency of infections?

Administer an over-the-counter decongestant.

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?

a feeling of swelling at the back of the throat After an initial hoarseness lasting longer than a month, clients with laryngeal cancer will feel a sensation of swelling or a lump in the throat or in the neck. Weight loss often occurs later in the progression of laryngeal cancer due to reduced calorie intake as a result of impaired swallowing and pain. Clients with laryngeal cancer may report burning in the throat when swallowing hot or citrus liquids. Clients with obstructive sleep apnea may experience a morning headache.

The volume of the IV medication is 50 mL. The time for infusion is 30 minutes or 0.5 hr. 50 mL/0.5 hr = 100 mL/1 hr.

a feeling of swelling at the back of the throat After an initial hoarseness lasting longer than a month, clients with laryngeal cancer will feel a sensation of swelling or a lump in the throat or in the neck. Weight loss often occurs later in the progression of laryngeal cancer due to reduced calorie intake as a result of impaired swallowing and pain. Clients with laryngeal cancer may report burning in the throat when swallowing hot or citrus liquids. Clients with obstructive sleep apnea may experience a morning headache.

17. The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently?

airway patency

The nurse is educating a patient diagnosed with acute bacterial rhinosinusitis about interventions that may assist with symptom control. What should the nurse include in this information? (Select all that apply.)

apply heat to promote drainage increase the humidity in the home ensure adequate fluid intake The nurse instructs the patient about methods to promote drainage of the sinuses, including humidification of the air in the home, the use of warm compresses to relieve pressure, and increasing fluid intake.

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 The nurse should encourage a client undergoing laryngeal surgery to practice deep breathing and coughing every 2 hours while the client is awake. These measures prevent atelectasis and promote effective gas exchange. Monitoring for signs of dysphagia and providing meticulous mouth care every 4 hours are the interventions related to the client's caloric intake.

The nurse is caring for a client diagnosed with rhinosinusitis. The physician has ordered the client to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the client that a common side effect of this medication is

epistaxis Common side effects of budesonide (Rhinocort) include epistaxis, pharyngitis, cough, nasal irritation, and bronchospasm.

The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?

Administer an over-the-counter decongestant. Explanation: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opens the nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best.

A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about?

Amoxicillan- clavulanic acid A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about?

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. Explanation: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.

A client with acute viral rhinosinusitis is being seen in a clinic. The nurse is providing discharge instructions and includes the following information:

Avoid air travel. Explanation: Information that the nurse should include for a client with acute viral rhinosinusitis is to avoid air travel. Other nursing interventions include referring the client to a physician if severe pain occurs when palpating the sinuses and humidifying the air in the home to promote drainage. Antibiotic therapy is not indicated for a viral infection.

The nurse is to make a room assignment for a client diagnosed with an upper respiratory infection. The other clients with empty beds in the room are listed in the accompanying chart. The best room assignment for the new client would be with Client

B The nurse needs to make the appropriate room assignment based on the client's problems, safety, and risk for infection to others. The client with an upper respiratory infection may transmit infection to susceptible people. Clients A, C, and D have increased susceptibility for infection because of immunosuppression or surgery.

A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to

Blow the nose before applying medication into the nares. Explanation: The nurse instructs the client to blow the nose before administering the nasal medication. The client should keep the head upright, not tilted back. The client should wait at least 1 minute before administering the second spray and clean the container after each use.

A 13-year-old soccer player presents to the emergency room with a fractured nose. The patient's mother is given which of the following post-discharge instructions? Select all that apply.

Check for any unusual changes in breathing during the first 48 hours. Observe for any clear drainage from either nostril. Elevate the head of the bed for sleeping during the first week. Restrict from sports activities for 6 weeks. Ice or cold compresses are applied *four to six times a day, for several days*, until the swelling is decreased. Packing is inserted to control bleeding. It would not be used to reshape the nose.

A patient prescribed a medication for hypertension started taking it 3 days ago and arrives in the emergency department with an edematous face and tongue and having a difficult time speaking. What medication is the nurse aware of that may produce this type of side effect?

Enalapril (Vasotec) Explanation: Use of ACE inhibitors, such as enalapril (Vasotec), is a risk factor for laryngeal obstruction resulting from edema of the throat as a result of a side effect of the drug.

Which of the following is a priority nursing intervention that the nurse should perform for a patient who has undergone surgery for a nasal obstruction?

Ensure mouth breathing For a patient who has undergone surgery for a nasal obstruction, it is important for the nurse to emphasize that nasal packing will be in place postoperatively, necessitating mouth breathing. The nurse applies an ice pack to reduce pain and swelling and not a warm pack. The nurse recommends the use of a splint and the application of pressure to the convex portion of the nose in case of a nasal fracture.

Which is the priority nursing diagnosis for a client undergoing a laryngectomy?

Ineffective airway clearance Explanation: The priority nursing diagnosis is Ineffective airway clearance, utilizing the ABCs. Imbalanced nutrition: Less than body requirement, impaired verbal communication, and anxiety and depression are all potential nursing diagnoses, but the question is asking for the priority nursing diagnosis for this patient. The priority is to identify any issues related to impaired airway.

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 Ineffective airway clearance can lead to respiratory depression, which necessitates immediate intervention.

The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently?

airway patency The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation. The priorities are always airway, breathing, and then circulation.

A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes

gastroesophageal reflux disease (GERD) The nurse should ask whether the client has a medical history of GERD. Laryngitis is common in older adults and may be secondary to GERD. Older adults are more likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. COPD, CHF, and RF are not associated with laryngitis in the older adult.

A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?

group-A, beta hemolytic streptococci Viral infection causes most cases of acute pharyngitis. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus. Bacterial infection accounts for the remainder of cases. Ten percent of adults with pharyngitis have group A beta-hemolytic streptococcus (GABHS), which is commonly referred to as group A streptococcus (GAS) or streptococcal pharyngitis.

A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis?

group-A, beta-hemolytic streptococcus The adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. Infection of the adenoids frequently accompanies acute tonsillitis. Frequently occurring bacterial pathogens include group A, beta-hemolytic streptococcus, the most common organism.

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 for over 2 weeks duration Hoarseness of more than 2 weeks' duration occurs in the patient with cancer in the glottic area, because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh, raspy, and lower in pitch. Later symptoms include dysphasia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath. Cervical lymph adenopathy, unintentional weight loss, a general debilitated state, and pain radiating to the ear may occur with metastasis.

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?

hypercapnia Repetitive apneic events result in hypoxia and hypercapnia, which triggers a sympathetic response (increased heart rate and decreased tone and contractility of smooth muscle).

Which clinical manifestation of hemorrhage is related to carotid artery rupture?

increased pulse rate The nurse monitors vital signs for changes, particularly increased pulse rate, decreased blood pressure, and rapid, deep respirations. Cold, clammy, pale skin may indicate active bleeding.

A client is postoperative immediately following a total laryngectomy. The client's respirations are 32 breaths/minute, shallow, and noisy. The tracheostomy pad is moist with mucus. Pulse oximetry is 88%. The client's eyes are wide open, and the client appears apprehensive. What is a priority nursing concern?

ineffective airway clearance All may be appropriate nursing diagnoses for this client. The nurse would follow Maslow's hierarchy of needs and ABCs (airway, breathing, circulation) to determine the highest priority. Ineffective airway clearance is the nursing diagnosis of highest priority.

A client presents to the ED with a suspected allergic reaction. The client is experiencing laryngeal edema, which is causing obstruction, and is demonstrating retractions in the neck during inspiration. Which is the nurse's priority intervention?

prepare to administer subcutaneous epinephrine and corticosteroids The use of accessory muscles to maximize airflow is often manifested by retractions in the neck during inspiration and is an ominous sign of impending respiratory distress. The client's obstruction is caused by edema resulting from an allergic reaction, and treatment should include immediate administration of subcutaneous epinephrine and a corticosteroid. The other interventions may be indicated for a client with a laryngeal obstruction; however, in this instance the most appropriate intervention to treat the client's laryngeal edema is the administration of the medications.

34. The nurse is caring for a client with a new tracheostomy. Which of the following nursing diagnoses are priorities? Select that apply.

💊Ineffective Airway Clearance related to increased secretions 💊Impaired Gas Exchange related to shallow breathing and anxiousness

The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?

a face mask A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device.

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. Explanation: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.

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 Explanation: A nasal fracture very often produces bleeding from the nasal passage. As a rule, bleeding is controlled with the use of packing

2. The nurse is caring for a client status postnasal polypectomy. What would the nurse instruct this client to report?

excessive swallowing

When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?

test the nasal drainage for glucose Because cerebrospinal fluid (CSF) contains glucose, testing nasal drainage for glucose helps determine whether it's CSF. The nurse should look for a halo sign only if the drainage is blood tinged. A client with a suspected CSF leakage shouldn't blow his nose; doing so could increase the risk of injury. The nurse should contact the physician after completing the assessment.

The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?

total laryngectomy In more advanced cases, total laryngectomy may be the treatment of choice. Partial laryngectomy, laser surgery, and radiation therapy are not the treatment of choice for advanced cases of laryngeal cancer.

16. The nurse in the walk-in clinic obtains a history of an upper respiratory infection with a red, sore throat. The client has been febrile for 3 days. Which nursing assessment should be stressed?

voiding

Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?

Ensure mouth breathing Explanation: For a client who has undergone surgery for a nasal obstruction, it is important for the nurse to emphasize that nasal packing will be in place postoperatively, necessitating breathing through the mouth. The nurse applies an ice pack to reduce pain and swelling and not a warm pack. The nurse recommends the use of a splint and the application of pressure to the convex portion of the nose in case of a nasal fracture.

5. A client visits the physician's office concerned about possible sleep apnea. The client states he lives alone and fears that he will not awaken from sleep. The client states that he has many symptoms which may indicate sleep apnea. Which symptom, stated by the client, is not a symptom of sleep apnea?

I have pressure in the middle of my chest night."

Stiffness of the neck or inability to bend the neck is referred to as which of the following?

Nuchal rigidity Nuchal rigidity is the stiffness of the neck or inability to bend the neck. Aphonia is impaired ability to use one's voice due to distress or injury to the larynx. Xerostomia is dryness of the mouth from a variety of causes. Dysphagia is difficulty swallowing.

A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for

Nuchal rigidity Explanation: Potential complications of acute bacterial rhinosinusitis are nuchal rigidity and severe headache. Hypertension may be a result of over-the-counter decongestant medications. Nausea may be a result of nasal corticosteroids.

When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided?

Swimming Explanation: The nurse provides the client and family with the following postoperative instructions: water should not enter the stoma because it will flow from the trachea to the lungs. Therefore, the nurse instructs the client to avoid swimming and to use a handheld shower device when bathing. The nurse also suggests that the client wear a scarf over the stoma to make the opening less obvious. The nurse encourages the client to cough every 2 hours to promote effective gas exchange.

3. The emergency department nurse is assessing a client following a motor vehicle accident. The nurse notes facial deformities with swelling and bleeding and a clear drainage coming from the nares. Which diagnostic test is completed to determine whether the clear drainage is cerebrospinal fluid?

Teat fluid with a Dextrostix

33. The nurse is caring for a client in a physician's office whose X-ray of the sinus reveals exudate in the maxillary sinus. Which equipment must the nurse have present in the room?

irrigation equipment

A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?

laryngeal cancer Persistent hoarseness (longer than 2 weeks) is usually the earliest symptom.

A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by

telling the client to sit upright with the head tilted forward Hemorrhage or massive bleeding from the nose is called epistaxis. Initial interventions include having the client sit upright with the head tilted forward to prevent swallowing and aspiration of blood. Tilting the head back will encourage the client to swallow and possibly aspirate blood. Pressure is applied to the soft outer portion of the nose against the midline septum, not the upper and hard portion of the nose. Pressure is also applied continuously for 5 to 10 minutes.

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub?

20 ml or less The pleural space, located between the visceral and parietal pleura, normally contains 20 mL of fluid or less. The fluid helps lubricate the visceral and parietal pleura.

A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:

A permanent tracheal stoma would be necessary. Explanation: A total laryngectomy will result in a permanent stoma and total loss of voice. A partial laryngectomy involves the removal of one vocal cord. The voice is spared with the supraglottic laryngectomy. Removal of a portion of the vocal cord occurs with a hemilaryngectomy.

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 Explanation: With severe respiratory distress in a status post adenoidectomy client, the nurse would suspect an airway issue related to edema of the upper airway. The scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy tube.

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 The signs and symptoms described are consistent with acute pharynigitis. The nurse needs to assess for a fever higher than 39.3°C. Findings will help to determine if the client requires antibiotic therapy. The client may also experience headache, myalgias, and nausea. The nurse needs to assess for these symptoms also, and symptomatic treatment would then be provided.

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." Explanation: An endotracheal tube provides a patent airway for clients who cannot maintain an adequate airway on their own. Tracheostomy tubes are inserted into a surgical opening in the trachea, called a tracheotomy. Clients receiving endotracheal intubation for the purpose of general anesthesia should not require long-term placement of the ET tube. Positive-pressure ventilators require intubation and are used for clients who are under general anesthesia. They are also used for clients with acute respiratory failure, primary lung disease, or comatose.

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." Explanation: An endotracheal tube provides a patent airway for clients who cannot maintain an adequate airway on their own. Tracheostomy tubes are inserted into a surgical opening in the trachea, called a tracheotomy. Clients receiving endotracheal intubation for the purpose of general anesthesia should not require long-term placement of the ET tube. Positive-pressure ventilators require intubation and are used for clients who are under general anesthesia. They are also used for clients with acute respiratory failure, primary lung disease, or who are comatose.

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." Management of viral rhinitis consists of symptomatic therapy that includes adequate fluid intake, rest, prevention of chilling, and use of expectorants as needed. Warm saltwater gargles soothe the sore throat, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, relieve aches and pains. Antibiotics are not prescribed because they do not affect the virus causing the patient's signs and symptoms. Topical nasal decongestants should be used with caution. The symptoms of viral rhinitis may last from 1 to 2 weeks.

A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client?

"gargle with a warm salt solution" A warm saline solution will help with removal of thick mucus and halitosis. It will be a gentle gargle, because a vigorous gargle may cause bleeding. A sore throat may be present for 3 to 5 days. Hot foods should be avoided.

A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority?

Administer one intramuscular injection of penicillin. Explanation: If a nurse is concerned that a client may not perform follow-up treatment for streptococcal pharyngitis, the highest priority is to administer penicillin as a one-time injection dose. Oral penicillin is as effective and less painful, but the client needs to take the full course of treatment to prevent antibiotic-resistant germs from developing. The nurse should provide oral and written instructions for the client, but this is not as high a priority as administering the penicillin. Having a homeless friend monitor the client's care does not ensure that the client will follow therapy.

The antibiotic of choice utilized in the treatment of acute bacterial rhinosinusitis (ABRS) includes which of the following?

Amoxicillin (Augmentin) Explanation: Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanate (Augmentin) is the antibiotic of choice. For patients who are allergic to penicillin, doxycycline (Vibramycin) or respiratory quinolones, such as levofloxacin (Levaquin) or moxifloxacin (Avelox), can be used. Other antibiotics previously prescribed to treat ABRS, including cephalosporins such as cephalexin (Keflex) and cefuroxime (Ceftin), are no longer recommended as they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.

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 Explanation: Herpes labialis is an infection that is caused by herpes simplex virus type 1 (HSV-1). It is characterized by an eruption of small, painful blisters on the skin of the lips, mouth, gums, tongue, or the skin around the mouth. The blisters are commonly referred to as cold sores or fever blisters. Medications used in the management of herpes labialis include acyclovir (Zovirax) and valacyclovir (Valtrex), which help to minimize the symptoms and the duration or length of flare-up.

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply.

Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 Nasal flaring with abdominal retractions Lung sounds of stridor Increased respiratory effort The nurse would be calling to report signs of respiratory distress. This includes nasal flaring with abdominal retractions, stridor and an increased respiratory effort. Also arterial blood gases with an elevated CO2 and lower oxygen level indicates respiratory compromise. An increased respiratory rate occurs in respiratory compromise. Administration of a corticosteroid decreases inflammation over a period of time.

You are mentoring a new graduate nurse. Today, the two of you are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would you respond? Select all that apply.

Aspiration Infection Injury to the laryngeal nerve Explanation: The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall.

You are an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would you be sure to include in your workshop? Select all that apply.

Correct response: Alcohol Tobacco Industrial pollutants

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 An endotracheal tube is inserted through the mouth or nose into the trachea to provide a patent airway for clients who cannot maintain an adequate airway on their own. The scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy tube.

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 The nurse knows that laryngeal cancer is most common in people 60 to 70 years of age, with men affected more frequently than are women. The client's history of chronic laryngitis may also predispose him to the development of laryngeal cancer. Sore throat, difficulty or pain on swallowing, fever, and malaise are the most common symptoms of adenoiditis. Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. This is another term for the common cold. Symptoms include sneezing, sore throat, and nasal congestions. Clients with a peritonsillar abscess experience difficulty and pain with swallowing, fever, malaise, ear pain, and difficulty talking.

You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

Noisy breathing Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following a tracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.

The nurse is caring for a patient admitted with a diagnosis of bacterial pharyngitis. The nurse anticipates the patient will be ordered which of the following medications?

Penicillin Explanation: Treatment of choice for bacterial pharyngitis is penicillin. Penicillin V potassium taken for 5 days is the regimen of choice. Traditionally, penicillin was administered as a single injection; however, oral forms are used more often and are as effective and less painful than injections. Penicillin injections are recommended only if there is a concern that the patient will not comply with therapy. Robitussin DM may be used as an antitussive. For severe sore throats aspirin or Tylenol, or Tylenol with codeine may be given.

6. The nurse is providing suggestions to a client diagnosed with the effects of coryza. Which home remedy is appropriate when combined with medical treatment for pharyngitis?

Salt water gargle

A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client:

Sleep with the head of bed elevated. General nursing interventions for chronic rhinosinusitis include teaching the client how to provide self-care. These measures include elevating the head of the bed to promote sinus drainage. Caffeinated beverages and alcohol may cause dehydration. Saline irrigations are used to eliminate drainage from the sinuses.

The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care?

apply an ice pack Following a nasal fracture, *the nurse applies ice and encourages the client to keep the head elevated*. The nurse instructs the client to apply ice packs to the nose to decrease swelling. The packing inserted to stop the bleeding may be uncomfortable and unpleasant, and obstruction of the nasal passages by the packing forces the client to breathe through the mouth. This, in turn, causes the oral mucous membranes to become dry. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. Applying direct pressure is not indicated in this situation.

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?

bleeding The nurse should instruct the client to report bleeding immediately. Delayed bleeding may occur when the healing membrane separates from the underlying tissue — usually 7 to 10 days postoperatively. Difficulty swallowing and throat pain are expected after a tonsillectomy and typically are present even before the client is discharged. Sudden difficulty talking wouldn't occur after discharge if the client could talk normally at the time of discharge, because swelling doesn't take that long to develop.

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 head turned to the side The most comfortable position for the client in the immediate postoperative period is prone, not semi-Fowler's. The client's head is turned to the side to allow drainage from the mouth. The oral airway is removed after the gag reflex has returned. An ice collar, not warm compress, is applied to the neck area.

A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to

check the clear fluid for glucose The client's signs and symptoms are consistent with a fracture of the nose. Clear fluid draining from either nostril suggests leakage of *cerebrospinal fluid*. This can be checked by assessing for glucose, which is in cerebrospinal fluid. This finding is important to identify, because infection can be transmitted through the opening in the cribriform plate. Other options, such as applying an ice pack to the nose and administering ibuprofen, are appropriate interventions but not most important for this client. Reassuring the client that the nose is not fractured is premature until all assessments are completed.

The nurse knows that there are three types of chronic pharyngitis. Which of the following is characterized by numerous swollen lymph follicles on the pharyngeal wall?

chronic granular Chronic granular pharyngitis is characterized by numerous swollen lymph follicles on the pharyngeal wall. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane.

What client would be most in need of an endotracheal tube?

comatose clients Examples include those with respiratory difficulty, comatose clients, those undergoing general anesthesia, and clients with extensive edema of upper airway passages.

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

continuous positive airway pressure (CPAP) CPAP is the most effective treatment for OSA because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient must be breathing independently. BiPAP ventilation offers independent control of inspiratory and expiratory pressure while providing pressure support ventilation. Mechanical ventilation is not the most effective treatment for OSA. Administration of low-flow nasal oxygen at night can help relieve hypoxemia in some patients but has little effect on the frequency or severity of apnea.

24. The nurse is caring for a client with an upper respiratory disorder. The client states he have a hacky, nonproductive cough, which wakens him during the night. Which over-the- counter medication would the nurse suggest to diminish the cough during the night?

detromethorphan

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 The client with a total laryngectomy is not able to speak. Communication needs to be established using an alternate method. The client typically has difficulty with swallowing due to edema in the immediate postoperative period. Alternate forms of nutrition are used. The tracheostomy cuff is often deflated for periods of time. The head of the bed is maintained in a semi-Fowler's position to decrease edema.

When caring for a client who has just had a total laryngectomy, the nurse should plan to:

develop an alternative communication method. A client with a laryngectomy can't speak, but still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. After a laryngectomy, edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury to the tracheal mucosa, the nurse should deflate the tracheostomy cuff or use the minimal leak technique. To decrease edema, the nurse should place the client in semi-Fowler's position.

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 The principal causes are the spread of an infection from the nasal passages to the sinuses and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis because trapped secretions readily become infected. Client with persistent sinus infections may have allergies, nasal polyps, or a deviated septum. Eating a well-balanced diet that includes but does not rely exclusively on protein is a measure that may help reduce incidences of sinusitis. Getting plenty of rest is a measure that may help reduce incidences of sinusitis. Increased exposure to the health care environment is not a specific cause of sinusitis, which is more commonly caused by allergies or blockage of the nasal passages.

The nurse is instructing a client who is scheduled for a laryngectomy about methods of laryngeal speech. Which best describes tracheoesophageal puncture (TEP)?

it requires insertion of a prosthesis into the trachea TEP requires a surgical opening in the posterior wall of the trachea, followed by the insertion of a prosthesis such as a Blom-Singer device. An artificial larynx is a throat vibrator held against the neck that projects sound into the mouth. With esophageal speech, the client forms words with the lips. Esophageal speech causes the voice quality to be lower pitched and gruff sounding.

As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that:

laryngeal cancer is one of the most preventable types of cancer Laryngeal cancer is one of the most preventable types of cancer; it can be prevented by abstaining from excessive drinking and smoking. Inhaling noxious fumes, such as in polluted air, is a risk factor for laryngeal cancer. Roughly 80% of laryngeal cancer cases occur in men. Squamous cell carcinoma accounts for most cases of laryngeal cancer.

Stiffness of the neck or inability to bend the neck is referred to as

nuchal rigidity Nuchal rigidity is stiffness of the neck or inability to bend the neck. Aphonia is impaired ability to use one's voice due to distress or injury to the larynx. Xerostomia is dryness of the mouth from a variety of causes. Dysphagia is difficulty swallowing.

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 1-10 The client statement of relief of pain to level 3 indicates improvement of the problem. The other options are actually interventions or actions that can help achieve a long-term goal of relief of pain.

A nurse is caring for a client experiencing laryngeal obstruction. What clinical finding should lead the nurse to anticipate mechanical ventilation for the client?

retractions in the neck during inspiration The nurse anticipates mechanical ventilation if the client is having neck retractions during inspiration. Rhonchi in the bronchial region is heard lower in the airways and crackles are heard in the base of the lungs. Diminished breath sounds that occur throughout are indicative of airway obstruction, not laryngeal swelling.

A client who has an altered level of consciousness is receiving a tube feeding. Clients receiving tube feeding should be placed in which position?

semifowler's of higher A client who has an altered level of consciousness is receiving a tube feeding. Clients receiving tube feeding should be placed in which position?

The nurse in the ICU is caring for a client with a nasotracheal tube. Because of the tube placement, the nurse understands that the client is at risk for developing

sinus infection Clients with nasotracheal and nasogastric tubes in place are at risk for developing sinus infections. Thus, accurate assessment of clients with these tubes is critical. Removal of the nasotracheal or nasogastric tube as soon as the client's condition permits allows the sinuses to drain, possibly avoiding septic complications. Severe epistaxis is not a complication of nasotracheal placement. Subperiosteal abscess and orbital cellulitis are complications of chronic rhinosinusitis.

13. The nurse is mentoring a new graduate nurse, caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would the nurse respond? Select all that apply.

💊Aspiration 💊Infection 💊Injury to the laryngeal nerve

Most cases of acute pharyngitis are caused by which of the following?

Viral infection Explanation: Most cases of acute pharyngitis are caused by viral infection. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus.

1. The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?

a face mask

7. The nurse is caring for a client following sinus surgery. When assessing the client, the nurse asks him how many fingers are being held up. Why does the nurse assess postoperative visual acuity?

assess damage to the optic nerve

When a patient has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the patient very carefully because he or she is at high risk for

carotid artery hemorrhage. Explanation: The carotid artery lies close to the stoma and may rupture from erosion if the wound does not heal properly. Pulmonary embolism is associated with immobility. Dehydration may lead to poor wound healing and breakdown. Pneumonia is a risk for any postoperative patient.

Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require?

emotional support Clients with a malignancy of the larynx require emotional support before and after surgery and help in understanding and choosing an alternative method of speech. It does not require a referral for counseling or vocational training. It also does not require family counseling.

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." Explanation: A sudden and complete loss of voice and cough are symptoms of laryngitis. The nurse instructs the client to avoid irritants, such as smoking. Voice rest is indicated. Whispering places stress on the larynx. Inhaling cool steam or aerosal aids in the treatment. Dry air may make the symptoms worse. A "tickle" in the throat that many clients report is actually worsened with cold liquids.

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?" Persistent hoarseness may signal throat cancer, which commonly is associated with tobacco use. To assess the client's risk for throat cancer, the nurse should ask about smoking habits. Although straining the voice may cause hoarseness, it wouldn't cause hoarseness lasting for 1 month. Consuming red meat or spicy foods isn't associated with persistent hoarseness.

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?

"Family members should continue to talk to the client." Explanation: Commonly, family members are reluctant to talk to the client who has had a total laryngectomy and can no longer speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing.

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." Explanation: A warm saline solution will help with removal of thick mucus and halitosis. It will be a gentle gargle, because a vigorous gargle may cause bleeding. A sore throat may be present for 3 to 5 days. Hot foods should be avoided.

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." Explanation: Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes.

The nurse is assessing a patient who smokes 2 packs of cigarettes per day and has a strong family history of cancer. What early sign of cancer of the larynx does the nurse look for in this patient?

Affected voice sounds Explanation: Hoarseness of more than 2 weeks' duration occurs in the patient with cancer in the glottic area because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh, raspy, and lower in pitch. Affected voice sounds are not always early signs of subglottic or supraglottic cancer, however. The patient may complain of a persistent cough or sore throat and pain and burning in the throat, especially when consuming hot liquids or citrus juices. A lump may be felt in the neck. Later symptoms include dysphagia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath.

You are caring for a client who has just been told they have advanced laryngeal cancer and will have to have a total laryngectomy. You are doing preoperative teaching with this client. What do you know is a subject you should cover?

Alternative methods of communication Explanation: Discuss alternative methods of communication and identify which method the client prefers. Visiting hours, pain and post operative nutrition are not generally covered at this point in preoperative teaching.

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

Amoxicillin Explanation: Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid is the antibiotic of choice. For clients who are allergic to penicillin, doxycycline or respiratory quinolones, such as levofloxacin or moxifloxacin, can be used. Other antibiotics previously prescribed to treat ABRS, including cephalosporins such as cephalexin and cefuroxime, are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.

The nurse is caring for a client experiencing laryngeal trauma. Upon assessment, swelling and bruising is noted to the neck. Which breath sound is anticipated?

Audible stridor without using a stethoscope Explanation: The nurse anticipates hearing audible stridor without needing a stethoscope due to the neck swelling narrowing the airway. Rhonchi in the bronchial region is heard lower in the airways and crackles are heard in the bases of the lungs. Diminished breath sounds that occur throughout are indicative of airway obstruction and not indicative of laryngeal swelling.

The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Auscultate lung sounds.

20. The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the followng nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Eauscultate lung sounds

The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client?

Avoid sports activities for 6 weeks. Explanation: The nurse instructs the client to avoid sports activities for 6 weeks. There is no indication for the client to refrain from taking oral fluids. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. The client should take analgesic agents, such as acetaminophen or NSAIDs (i.e., ibuprofen or naproxen), to decrease nasal discomfort, not aspirin. The client does not need to use nasal drops when nasal packing is in place.

Which of the following methods most resembles normal speech following a total laryngectomy?

Blom-Singers voice prosthesis The Blom-Singer voice prosthesis most resembles normal speech. With esophageal speech, patients compress air into the esophagus and expel it, setting off a vibration of the pharyngeal esophageal segment. With electrolarynx, a battery-powered apparatus projects sound into the oral cavity. When the mouth forms words (articulation), the sounds from the electric larynx becomes audible words. Lip speaking is available during the immediate postoperative period. It does not resemble normal speech.

Which assessment finding puts a client at increased risk for epistaxis?

Cocaine use Explanation: Using nasally inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased vascularity of the nasal passages. A dry environment (not a humidified one) increases the risk of epistaxis. Hypertension, not hypotension, increases the risk of epistaxis. A history of nasal surgery doesn't increase the risk of epistaxis.

A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

Correct response: "Keep the stoma moist." Explanation: The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities.

The nurse is assessing a patient in the clinic, and upon physical assessment the patient demonstrates displacement of the sternum. This would be documented as which of the following conditions?

Correct response: Pigeon chest Explanation: Pigeon chest may occur with rickets, Marfan's syndrome, or severe kyphoscoliosis. A barrel chest is seen in patients with emphysema and occurs as a result of over-inflation of the lungs. A funnel chest occurs when there is a depression in the lower portion of the sternum. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine.

Another term for clergyman's sore throat is

Correct response: chronic granular pharyngitis. Explanation: In clergyman's sore throat, the pharynx is characterized by numerous swollen lymph follicles. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane.

28. 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.

Wound drains, inserted during the laryngectomy, stay in place until what criteria are met?

Drainage is <30 mL/day for 2 consecutive days. Explanation: Drains are removed when secretions are minimal, which usually is less than 30 mL for 48 straight hours.

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 their 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 Explanation: An endotracheal tube is inserted through the mouth or nose into the trachea to provide a patent airway for clients who cannot maintain an adequate airway on their own. The scenario does not indicate infection, post operative bleeding, or a plugged tracheostomy tube.

A client stops breathing during sleep as a result of repetitive upper airway obstruction. To help decrease the frequency of the apneic episodes, the nurse intervenes by informing the client to:

Eliminate alcohol ingestion. Explanation: The client's symptoms are consistent with obstructive sleep apnea. Initial treatment includes avoidance of alcohol and hypnotic medications. Clients are told to not sleep on their backs. Administration of nasal oxygen may help with hypoxemia but has little effect on the frequency of apnea.

15. A nurse is caring for a client following nasal surgery. Which assessment finding best indicates current bleeding?

Frequent swallowing

A 76-year-old man presents to the ED complaining of "laryngitis." The triage nurse should ask if the patient has a past medical history that includes which of the following?

Gastroesophageal reflux disease (GERD) Explanation: The nurse should ask if the patient has a past medical history of GERD. Laryngitis in the older adults is common and may be secondary to GERD. Older adults are more likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. COPD, CHF, and RF are not associated with laryngitis in the older adult.

The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?

Hoarseness for 2 weeks Explanation: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity.

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 Explanation: All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis.

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. Explanation: The client should wash the hands before any care of the surgical site, particularly cleansing of the inner cannula. The other activities are appropriate outcomes for a client following laryngectomy.

The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs?

Initiate enteral feedings. Explanation: Postoperatively, the client may not be permitted to eat or drink for at least 7 days. Alternative sources of nutrition and hydration include IV fluids, enteral feedings through a nasogastric or gastrostomy tube, and parenteral nutrition. Once the client is permitted to resume oral feedings, thick liquids are offered; sweet foods are avoided because they cause increased salivation and decrease the client's appetite. The client's taste sensations are altered for a while after surgery because inhaled air passes directly into the trachea, bypassing the nose and the olfactory end organs. In time, however, the client usually accommodates to this change and olfactory sensation adapts; thus, seasoning is based on personal preferences.

Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has?

Laryngeal cancer Explanation: Later, the client notes a sensation of swelling or a lump in the throat, followed by dysphagia and pain when talking. Hoarseness is not indicative of pharyngeal cancer; laryngeal polyps; or cancer of the tonsils.

The nurse is caring for a client receiving radiation therapy for laryngeal cancer. Which is a late complication of radiation therapy?

Laryngeal necrosis Explanation: Late complications of radiation therapy include laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy.

A patient diagnosed 2 weeks ago with acute pharyngitis comes to the clinic stating that the sore throat got better for a couple of days and is now back along with an earache. What complications should the nurse be aware of related to acute pharyngitis? (Select all that apply.)

Mastoiditis Otitis media Peritonsillar abscess Explanation: Uncomplicated viral infections usually subside promptly, within 3 to 10 days after onset. However, pharyngitis caused by more virulent bacteria, such as GAS, is a more severe illness. If left untreated, the complications can be severe and life threatening. Complications include rhinosinusitis, otitis media, peritonsillar abscess, mastoiditis, and cervical adenitis. In rare cases, the infection may lead to bacteremia, pneumonia, meningitis, rheumatic fever, and nephritis.

The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

Noisy breathing Explanation: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following a tracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.

10. The nurse is receiving a client in the postanesthesia care unit (PACU) diagnosed with postoperative tonsillectomy and adenoidectomy. The unlicensed assistive personnel is assisting the client from the stretcher to the bed. The client remains drowsy from anesthesia. In which position would the nurse instruct the unlicensed assistive personnel to place the client?

On a side

A patient is diagnosed as being in the early stage of laryngeal cancer of the glottis with only 1 vocal cord involved. For what type of surgical intervention will the nurse plan to provide education?

Partial laryngectomy Explanation: A partial laryngectomy (laryngofissure-thyrotomy) is often used for patients in the early stages of cancer in the glottis area when only one vocal cord is involved.

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 Explanation: In a partial laryngectomy, a portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing. During a supraglottic laryngectomy, a tracheostomy is left in place until the glottic airway is established. Hemilaryngectomy is done by splitting the thyroid cartilage of the larynx in the midline of the neck, and the portion of the vocal cord is removed with the tumor. During a total laryngectomy, a complete removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea.

30. A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first?

Place a dilator in the stoma to maintain the opening.

Bleeding from the drains at the surgical site or with tracheal suctioning may signal the occurrence of hemorrhage. Which of the following is a clinical manifestations associated with hemorrhage?

Rapid, deep respirations Explanation: The nurse monitors the vital signs for increased pulse rate, decreased blood pressure, rapid deep respirations, restlessness, and delayed capillary refill. Cold, clammy skin may indicate active bleeding.

The nurse assesses a patient for possible acute pharyngitis. Which of the following clinical manifestations are consistent with this diagnosis? Select all that apply.

Red pharyngeal membranes Swollen lymphoid follicles White-purple exudates on the back of the throat A temperature >100.4°F Explanation: Acute pharyngitis is not characterized by a cough. All the other symptoms are present.

The nurse is caring for a geriatric client brought to the emergency department after being found by her children feeling poorly with an elevated temperature. Laboratory tests confirm influenza type A, a respiratory virus. Which medical treatment would the nurse anticipate in the discharge instructions? Select all that apply.

Rest Increased fluids Saline gargles Antitussives Explanation: Influenza type A is the most common cause of the flu initiated by a respiratory virus. Common discharge instructions include rest, increased fluids to thin respiratory secretions, saline gargles to help prevent a throat infection such a strep throat, and antitussives if the client is coughing. Antibiotics are not used with a virus unless a bacterial infection subsequently develops. Antiemetics are used for nausea and vomiting not commonly associated with a common respiratory virus.

A client is experiencing acute viral rhinosinusitis. The nurse is providing instructions about self-care activities and includes information about

Saline lavages to the nares Explanation: Saline lavages are used for acute rhinosinusitis and relieve symptoms, reduce inflammation, clear nasal passages of stagnant mucus, and reduce the development of opportunistic infections. Other methods that promote drainage of the sinuses are humidifying the air, not dehumidifying it, and warm compresses, not cold compresses, to the sinus cavities. Because this infection is viral, antibiotics are not indicated.

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 Explanation: The client should seek medical assistance if swallowing is impaired to prevent aspiration. Following Maslow's hierarchy of needs, airway clearance is the highest priority.

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 Explanation: The description of the fellow worker is a person who is choking. Following guidelines set by the American Heart Association, the nurse first stands behind the person who is choking.

The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?

Sudden restlessness Explanation: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube. A harsh cough and rhonchi in the lung fields is common with the presence of mucous secretions.

26. A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy?

Tell my wife about it. I do not want to touch it."

4. The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, "Elevate the head of the bed 45°." Which nursing goal is met in this assessment?

The client will have decreased edema.

The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, "Elevate the head of the bed 45°." This assists in meeting which nursing goal?

The client will have decreased edema. Explanation: Elevating the head of the bed 45° when the client is fully awake decreases surgical edema and increases lung expansion. At this point in the recovery, elevating the head of the bed will not decrease the surgical pain as pain medication will be needed. Elevating the head of the bed will not affect mentation nor increase the blood supply.

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 The nurse inspects the nasal mucosa for abnormal findings such as increased redness, swelling, exudate, and nasal polyps, which may develop in chronic rhinitis. The mucosa of the nasal turbinates may also be swollen (boggy) and pale bluish-gray. The nurse palpates the frontal and maxillary sinuses for tenderness, which suggests inflammation, and then inspects the throat by having the patient open the mouth wide and take a deep breath.

29. The nurse is caring for the client who presents to the clinic with hoarseness for 2 months. Further testing diagnoses laryngeal cancer with the treatment plan of a radical neck dissection. When reinforcing information provided by the physician, which nursing instruction is most correct?

The physician removes lymph nodes, muscles, and tissue

local community group. What should the nurse be sure to include regarding cold tablets 14. The nurse is presenting about upper respiratory infections at an educational event for a containing first-generation antihistamines?

They can cause urinary hesitancy.

tonsillectormy. Why would the nurse ask the client about the use of herbal supplements? 32. The nurse is performing a preoperative assessment on a client who is scheduled for a

They may prolong bleeding.

18. The nurse ls caring for a client in the physician's office with a potential sinus infoction. The physiclan orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, witten by the physlcian, is specifically ordered for this purpose?

Transillumination of the sinus

The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose?

Transillumination of the sinus Explanation: Transillumination and x-rays of the sinuses may show a change in the shape of or confirms that there is fluid in the sinus cavity. CBC with differential can note an elevated white blood cell count but not confirm fluid in the sinus cavity. A nasal culture can note bacteria in the nares. An MRI is an expensive procedure which is not typically prescribed for a potential infection and not specifically ordered to identify fluid in the sinus cavity.

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 Explanation: Wound drains, inserted during surgery, may be in place to assist in removal of fluid and air from the surgical site. Suction also may be used, but cautiously, to avoid trauma to the surgical site and incision. The nurse observes, measures, and records drainage. When drainage is less than 30 mL/day for 2 consecutive days, the physician usually removes the drains.

The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include?

You can use writing or a communication board to communicate." Explanation: If a total laryngectomy is scheduled, the client must understand that the natural voice will be lost but special training can provide a means for communicating. The client needs to know that until training is started, communication will be possible using the call light, through writing, or using a special communication board. The use of an electronic device is a long-term postoperative goal. The speech therapist will evaluate the client before surgery and establish a method of immediate postoperative communication.

31. A client recently diagnosed with laryngeal cancer and awaiting a laryngectomy was encouraged to attend a support group prior to surgery. The client asked the nurse about the name of the laryngeal speech method where the client speaks through the wall of the trachea with a device. The nurse is correct to provide teaching on which method?

a tracheoesophageal puncture

11. The nurse is caring for a client status after 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 Explanation: Loss of the ability to speak normally is a devastating consequence of laryngeal surgery and is certain with a total laryngectomy. Issues with self-esteem and deficient knowledge are possible, but less certain. Infection is a risk, but not a certainty.

A client who has been diagnosed with an early glottis cancer would likely undergo which type of surgery?

laser microsurgery Explanation: In early glottis cancer, early stage lesions are treated and removed with a laser process. Vocal cord stripping would be the surgical treatment for early stage vocal cord lesions. Partial laryngectomy is done to treat early-stage laryngeal cancer when only one cord is involved. Total laryngectomy is done when the cancer extends beyond the vocal cords.

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:

sit upright, leaning slightly forward. Explanation: Sitting upright and leaning slightly forward avoids increasing vascular pressure in the nose and helps the client avoid aspirating blood. Lying supine won't prevent aspiration of the blood. Nose blowing can dislodge any clotting that has occurred. Bending at the waist increases vascular pressure in the nose and promotes bleeding rather than halting it.

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

swimming. Explanation: Swimming is not recommended because a client with a laryngectomy can drown without submerging his or her face. Special precautions are needed in the shower to prevent water from entering the stoma. Wearing a loose-fitting plastic bib over the tracheostomy or simply holding a hand over the opening is effective. The nurse also suggests that the client wear a scarf over the stoma to make the opening less obvious. The nurse encourages the client to cough every 2 hours to promote effective gas exchange.

9. The nurse is caring for a client diagnosed with coryza, possibly from the rhinovirus. Vital signs are temperature: 101.2°F, pulse: 72 beats/minute, respirations: 28 breaths/minute, and blood pressure: 112/70 mm Hg. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are course in the bases. Which aftemoon assessment finding suggests the advancement to an infectious process?

temperature rise

27. The nurse is providing discharge instructions to a client diagnosed with postoperative tonsillectomy and adenoidectomy. Which discharge instructions would the nurse include? Select all that apply.

💊Avoid carbonated fluids. 💊Gargle with warm saline water. 💊Gradually increase fluids then add soft foods. 💊Apply an ice collar to the neck area.

19. The nurse is an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would the nurse be sure to include in the workshop? Select all that apply.

💊Industrial polluants 💊tôbacco 💊alcohol

21. The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply.

💊Lung sounds of wheezing 💊Arterial blood gases reporting a PaCO2 of 48 and a Pa02 of 84 💊Nasal flaring with abdominal retractions 💊Increased respiratory effort