Ch 22: Management of Patients with Upper Respiratory Tract Disorders (3)
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? pg. 572
Hoarseness for 2 weeks
During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events? pg. 568
Hypercapnia
A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in her teaching? pg. 579
"Cover the stoma whenever you shower or bathe."
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? pg. 577
"Family members should continue to talk to the client."
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of pg. 556
2 to 12 days
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: pg. 574
A permanent tracheal stoma would be necessary.
Wound drains, inserted during the laryngectomy, stay in place until what criteria are met? pg. 577
Drainage is <30 mL/day for 2 consecutive days.
Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require? pg. 576
Emotional support
Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction? pg. 570
Ensure mouth breathing
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 pg. 565
Ineffective airway clearance related to excess mucus production
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? pg. 577
Initiate enteral feedings.
A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for pg. 558
Nuchal rigidity
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? pg. 573
Partial laryngectomy
Which diagnostic test is used to confirm the diagnosis of maxillary and frontal sinusitis? pg. 557
Sinus aspirates
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? pg. 572
a feeling of swelling at the back of the throat
A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis? pg. 569
Apply direct continuous pressure.
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? pg. 523
Auscultate lung sounds.
Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy? pg. 574
impaired verbal communication
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately? pg. 563
Bleeding
A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client? pg. 564
"Gargle with a warm salt solution."
