Management of Patients with Upper Respiratory Tract Disorders

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?

100 mL/hr

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says: A. "I should become involved in a weight-loss program." B. "I need to keep my inhaler at my bedside." C. "I should sleep on my side all night long." D. "I should eat a high-protein diet."

A. "I should become involved in a weight-loss program."

Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy? A. Impaired verbal communication B. Chronic low self-esteem C. Deficient knowledge D. Risk for infection

A. Impaired verbal communication

Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction? A. Apply pressure to the convex portion of the nose B. Ensure mouth breathing C. Apply a warm pack postoperatively D. Provide a splint postoperatively

B. Ensure mouth breathing

A client exhibits a sudden and complete loss of voice and is coughing. The nurse states: A. The 'tickle' in your throat will improve with cold liquids." B. "It is fine to speak in a whisper. This does not strain your voice." C. "Do not smoke and voice being around others who are smoking." D. "Do not use a humidifier; it will make your problem worse."

C. "Do not smoke and voice being around others who are smoking."

Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)? A. Ceftin B. Levofloxacin C. Keflon D. Amoxicillin

D. Amoxicillin

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 ruse include in the client's care? A. Apply pressure to the convex of the nose B. Restrict fluid intake C. Position the patient in the side-lying position D. Apply an ice pack

D. Apply an ice pack

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? A. "Tell my wife about it, I do not want to touch it." B. "I must give up my love of pool aerobics." C. "I must carry tissues with me." D. "I will not be able to have the tracheostomy removed."

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

The first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is A. Amoxicillin-clavulanic acid B. Cefuroxime C. Ampicillin D. Cefprizil

A. Amoxicillin-clavulanic acid

A patient has herpes simplex infection that develops after having the common cold. What medication does the nurse anticipate will be administered for this infection? A. An antiviral agent such as acyclovir B. An ointment such as bacitracin C. An antihistamine such as Benadryl D. An antibiotic such as amoxicillin

A. An antiviral agent such as acyclovir

A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis? A. Apply direct continuous pressure B. Provide a nasal splint C. Place the client in a semi-Fowler's position D. Apply and mustache dressing

A. Apply direct continuous pressure

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? A. Apply nasal packing B. Administering nasal lavage C. Applying steroidal nasal spray D. Preparing the patient for a septoplasty

A. Applying nasal packing

Which assessment finding puts a client at increased risk of epistaxis? A. Cocaine use B. History of nasal surgery C. Hypotension D. Use of a humidifier at night

A. Cocaine use

Wound drains, inserted during the laryngectomy, stay in place until what criteria are met? A. Drainage is < 30 mL/day for 2 consecutive days B. The surgical site is dry with encrustations C. The stoma is healed, about 6 weeks after surgery D. The patient is able to assist with his own suctioning

A. Drainage is < 30 mL/day for 2 consecutive days

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. A. Hoarseness of more than 2-week's duration B. Persistent ulceration C. Cervical lymph adenopathy D. Dysphagia

A. Hoarseness of more than 2-week's duration

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? A. Initiate enteral feedings B. Encourage sweet foods C. Liberally season food D. Offer plenty of thin liquids

A. Iniiate enteral feedings

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to a 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.) A. Nasal flaring with abdominal retractions B. A decrease in respiratory rate C. Lung sounds of wheezing D. Administration of a corticosteroid inhaler for quick relief E. Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 F. Increased respiratory effort

A. Nasal flaring with abdominal retractions C. Lung sounds of wheezing E. Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 F. Increased respiratory effort

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? A. Partial laryngectomy B. Hemilaryngectomy C. Supra glitter laryngectomy D. Total laryngectomy

A. Partial laryngectomy

A nurse has pharyngitis and will be providing self-care at home. It is most important for the nurse to: A. Seek medical help is he experiences inability to swallow B. Properly dispose of used tissues C. Place an ice collar on the throat to relieve soreness D. Stay in bed when experiencing a fever

A. Seek medical help is he experiences inability to swallow

A client has had laryngeal surgery. What are the expected client outcomes? (Select all that apply.) A. The client's suture line remains intact B. The client maintains an adequate caloric intake C. The client can swallow without difficulty D. The client's breathing patterns improve E. The client can manage his or her own secretions

A. The client's suture line remains intact B. The client maintains an adequate caloric intake E. The client can manage his or her own secretions

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? A. The nasal mucosa B. The frontal sinuses C. The tracheal mucosa D. The buccaneers mucosa

A. The nasal mucosa

The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice? A. Total laryngectomy B. Radiation therapy C. Partial laryngectomy D. Laser surgery

A. Total laryngectomy

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 surrounds the lungs, to percent friction rub? A. No fluid is normally present B. 20 mL or less C. 20-40 mL D. More than 40 mL

B. 20 mL or less

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? A. Obtain vital sings B. Auscultate lung sounds C. Assess capillary refill D. Monitor heart rhythm

B. Auscultate lung sounds

A client has a red pharyngeal membrane, reddened tonsils, and enlarge cervical lymph nodes. This client also reports malaise and sore throat. The nurse needs to assess first for: A. Myalgias B. Fever C. Headache D. Nausea

B. Fever

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? A. A phobia following a football game B. Hoarseness for 2 weeks C. Epistaxis, twice last week D. Laryngitis following a cold

B. Hoarseness for 2 weeks

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? A. "Clean the tracheostomy tube with alcohol and water." B. "Limit the amount of protein in the diet." C. "Family members should continue to talk to the client." D. "Oral intake of fluids should be limited for 1 week only."

C. "Family members should continue to talk to the client."

A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of his disorder does the nurse anticipate educating the client about? A. Cephalexin B. Cefuroxime C. Amoxicillin-clavulant acid D. Clarithromycin

C. Amoxicillin-clavulant acid

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately? A. Difficulty swallowing B. Difficulty talking C. Bleeding D. Throat pain

C. Bleeding

When a client has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the client very carefully because of the high risk for: A. Pulmonary embolism B. Pneumonia C. Carotid artery hemorrhage D. Dehydration

C. Carotid artery hemorrhage

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? A. Plugged tracheostomy tube B. Postoperative bleeding C. Edema of the upper airway D. Infection

C. Edema of the upper airway

A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for: A. Mild headache B. Nausea C. Nuchal rigidity D. Hypertension

C. Nuchal rigidity

A nurse is providing instructions for a client with chronic rhinosinusitis. The nurse accurately tells the client: A. Caffeinated beverages are allowed B. Do not perform saline irrigation's to the nares C. Sleep with the head of the bed elevated D. You may drink 1 glass of alcohol daily

C. Sleep with the head of the bed elevated

When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided? A. Wearing a scarf over the stoma B. Hand-held showers C. Swimming D. Coughing

C. Swimming

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? A. "I have environmental allergies." B. "U used my voice in excess over the weekend." C. "I smoke a pack of cigarettes a day." D. "I was chewing ice chips all day long."

D. "I was chewing ice chips all day long."

A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: A. The voice was spared and a tracheostomy would be in place until the airway was established B. One vocal cord was removed along with a portion of the larynx C. A portion of the vocal cord was removed D. A permanent tracheal stoma would be necessary

D. A permanent tracheal stoma would be necessary

The nurse is providing instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client? A. Administer normal saline nasal drops as ordered B. Take aspirin for nasal discomfort C. Decrease the amount of daily fluids D. Avoid sports activities for 6 weeks

D. Avoid sports activities for 6 weeks

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care? A. Assess the tracheostomy cuff for leaks B. Maintain the client in a low-Fowler's position C. Encourage oral nutrition on the second postoperative day D. Develop an alternate method of communication

D. Develop an alternate method of communication

Select the nursing diagnosis that would warrant immediate healthcare provider notification. A. Acute pain related to upper airway irritation secondary to an infection B. Deficient fluid volume related to decreased fluid intake and increased fluid loss secondary to diaphoresis associated with a fever C. Deficient knowledge regarding prevention of upper airway infections, treatment regimens, and surgical procedure, or postoperative care D. Ineffective airway clearance related to excessive mucous production secondary to retained secretions and inflammation

D. Ineffective airway clearance related to excessive mucous production secondary to retained secretions and inflammation

The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand hat the drains will most likely be removed? A. When the patient states that there is discomfort and requests removal B. When the drainage tube comes out C. In 1 week when the patient no longer has serous drainage D. When the patient has less than 30 mL for 2 consecutive days

D. When the patient has less than 30 mL for 2 consecutive days