Upper Respiratory Conditions(Exam 3)

Apply direct continuous pressure.

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

a tracheoesophageal puncture

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?

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

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?

Place a dilator in the stoma to maintain the opening.

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?

Frequent swallowing

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

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

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?

Test fluid with a Dextrostix

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?

voiding

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?

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°." Which nursing goal is met in this assessment?

tobacco industrial polluants alcohol

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. A. region of country lived in B. tobacco C. age D. industrial polluants E. alcohol

temperature rise

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 afternoon assessment finding suggests the advancement to an infectious process?

Noisy breathing

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

Audible stridor without using a stethoscope

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?

To assess damage to the optic nerve

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?

irrigation equipment

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?

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?

edema of the upper airway

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?

excessive swallowing

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

Develop an alternate method of communication.

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

airway patency

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

Administer an over-the-counter decongestant.

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

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

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. A. Nasal flaring with abdominal retractions B. A decreased respiratory rate C. Administration of a corticosteroid inhaler for quick relief D. Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 E. Lung sounds of wheezing F. Increased respiratory effort

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

The nurse is caring for a client with a new tracheostomy. Which of the following nursing diagnoses are priorities? Select all that apply. A. Impaired Gas Exchange related to shallow breathing and anxiousness B. Knowledge Deficit related to care of the tracheostomy tube and surrounding site C. Ineffective Airway Clearance related to increased secretions D. Risk for Infection related to operative incision and tracheostomy tube placement E. DisturbedBodyImage

Sudden restlessness

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

detromethorphan

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?

a face mask

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?

auscultate lung sounds

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?

The physician removes lymph nodes, muscles, and tissue.

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?

Infection Aspiration Injury to the laryngeal nerve

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. A. Penetration of the anterior tracheal wall B. Infection C. Aspiration D. Absence of secretions E. Injury to the laryngeal nerve

Hoarseness for 2 weeks

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?

"I was chewing ice chips all day long."

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?

They may prolong bleeding.

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

They can cause urinary hesitancy.

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

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

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. A. Gradually increase fluids then add soft foods. B. Gargle with warm saline water. C. Avoid carbonated fluids. D. Postoperative bleeding most frequently occurs in the hours after surgery. E. Limit pain medications to the nighttime. F. Apply an ice collar to the neck area.

Salt water gargle

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?

on a side

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?