Ch. 27 Upper Respiratory
18. When assessing the patient on return to the surgical unit following a total laryngectomy and radical neck dissection, what would the nurse expect to find? a. A closed-wound drainage system b. A nasal endotracheal tube in place c. A nasogastric tube with orders for tube feedings d. A tracheostomy tube and mechanical ventilation
. a. Following a radical neck dissection, drainage tubes are often used to prevent fluid accumulation in the wound as well as possible pressure on the trachea. The patient has placement of a nasogastric tube to suction immediately after surgery, which will later be used to administer tube feedings until swallowing can be accomplished. A tracheostomy tube is in place but mechanical ventilation is usually not indicated.
6. The influenza vaccine is in short supply. Which group of clients would the public health nurse consider priority when administering the vaccine? 1. Elderly and chronically ill clients. 2. Child-care workers and children 3. Hospital chaplains and health-care workers. 4. Schoolteachers and students living in a dormitory.
1. The elderly and chronically ill are at greatest risk for developing serious complications if they contract the influenza virus
66. The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a surgical floor. Which information provided by the UAP requires immediate intervention by the nurse? 1. There is a small, continuous amount of bright-red drainage coming out from under the dressing of the client who had a radical neck dissection. 2. The client who has had a right upper lobectomy is complaining that the patient-controlled analgesia (PCA) pump is not providing any relief. 3. The client diagnosed with cancer of the lung is complaining of being tired and short of breath. 4. The client admitted with chronic obstructive pulmonary disease is making a whistling sound with every breath.
1. The most serious complication resulting from a radical neck dissection is rupture of the carotid artery. Continuous bright-red drainage indicates bleeding, and this client should be assessed immediately
62. The client is diagnosed with cancer of the larynx and is to have radiation therapy to the area. Which prophylactic procedure will the nurse prepare the client for? 1. Removal of the client's teeth and fitting for dentures. 2. Take antiemetic medications every four (4) hours. 3. Wear sunscreen on the area at all times. 4. Placement of a nasogastric feeding tube.
1. The teeth will be in the area of radiation and the roots of teeth are highly sensitive to radiation, which results in root abscesses. The teeth are removed and the client is fitted for dentures prior to radiation.
70. The HCP has recommended a total laryngectomy for a male client diagnosed with cancer of the larynx but the client refuses. Which intervention by the nurse illustrates the ethical principle of nonmalfeasance? 1. The nurse listens to the client explain why he is refusing surgery. 2. The nurse and significant other insist that the client have the surgery. 3. The nurse refers the client to a counselor for help with the decision. 4. The nurse asks a cancer survivor to come and discuss the surgery with the client
1. This is an example of nonmalfeasance, where the nurse "does no harm." In attempting to discuss the client's refusal, the nurse is not trying to influence the client; the nurse is merely attempting to listen therapeutically.
12. Delegation Decision: In planning the care for a patient with a tracheostomy who has been stable and is to be discharged later in the day, the RN may delegate which interventions to the licensed practical nurse (LPN) (select all that apply)? a. Suction the tracheostomy. b. Provide tracheostomy care. c. Determine the need for suctioning. d. Assess the patient's swallowing ability. e. Teach the patient about home tracheostomy care.
a, b, c. LPNs may determine the need for suctioning, suction the tracheostomy, and determine whether the patient has improved after the suctioning when caring for stable patients. They also may perform tracheostomy care using sterile technique. The patient's swallowing ability is assessed by a speech therapist, videofluoroscopy, or fiberoptic endoscopic evaluations. The RN will teach the patient about home tracheostomy care.
7. While the nurse is feeding a patient, the patient appears to choke on the food. Which symptoms indicate to the nurse that the patient has a partial airway obstruction (select all that apply)? a. Stridor b. Cyanosis c. Wheezing d. Bradycardia e. Rapid respiratory rate
a, b, c. With partial airway obstruction, choking, stridor, use of accessory muscles, suprasternal and intercostals retraction, flaring nostrils, wheezing, restlessness, tachycardia, cyanosis, and change in level of consciousness may occur. Partial airway obstruction may progress to complete obstruction without prompt assessment and treatment
1. A patient develops epistaxis upon removal of a nasogastric tube. What action should the nurse take? a. Pinch the soft part of the nose. b. Position the patient on the side. c. Have the patient hyperextend the neck. d. Apply an ice pack to the back of the neck
a. Direct pressure on the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes is indicated for epistaxis. In addition, have the patient upright and leaning forward to prevent swallowing blood.
14. Priority Decision: A patient's tracheostomy tube becomes dislodged with vigorous coughing. What should be the nurse's first action? a. Attempt to replace the tube. b. Notify the health care provider. c. Place the patient in high Fowler position. d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives.
a. If a tracheostomy tube is dislodged, the nurse should immediately attempt to replace the tube by grasping the retention sutures (if available) and spreading the opening. The obturator is inserted in the replacement tube, watersoluble lubricant is applied to the tip, and the tube is inserted in the stoma at a 45-degree angle to the neck. The obturator is immediately removed to provide an airway. If the tube cannot be reinserted, the health care provider should be notified and the patient should be assessed for the level of respiratory distress, positioned in semi-Fowler position, and ventilated with a manual resuscitation bag (MRB) only if necessary until assistance arrives.
16. The patient has been diagnosed with an early vocal cord malignancy. The nurse explains that usual treatment includes a. radiation therapy that preserves the quality of the voice. b. a hemilaryngectomy that prevents the need for a tracheostomy. c. a radical neck dissection that removes possible sites of metastasis. d. a total laryngectomy to prevent development of second primary cancers.
a. If laryngeal tumors are small, radiation is the treatment of choice because it can be curative and can preserve voice quality. Surgical procedures are used if radiation treatment is not successful or if larger or advanced lesions are present.
17. During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include? a. The postoperative use of nonverbal communication techniques b. Techniques that will be used to alleviate a dry mouth and prevent stomatitis c. The need for frequent, vigorous coughing in the first 24 hours postoperatively d. Self-help groups and community resources for patients with cancer of the larynx
a. With removal of the larynx, the patient will not be able to communicate verbally and it is important to arrange with the patient a method of communication before surgery so that postoperative communication can take place. Dry mouth and stomatitis result from radiation therapy. Vigorous coughing is not encouraged immediately postoperatively and information related to community resources is usually introduced during the postoperative period.
15. Surgical reduction of nasal fractures is usually performed how long after the fracture? a. Within 24 hours b. 3 to 7 days c. 2 to 3 weeks d. 2 months
b
16. Angioedema as a risk factor that leads to laryngeal obstruction is usually caused by: a. heavy alcohol use. b. a history of airway problems. c. the presence of foreign body. d. the use of ACE inhibitors.
b
17. To correctly perform the Heimlich maneuver, a person should forcefully apply pressure against the victim's: a. abdomen. b. diaphragm. c. lungs. d. trachea.
b
3. The nurse expects that emergency medical treatment may include insertion of a cotton pledget moistened with: a. an adrenergic blocking agent. b. a topical anesthetic. c. protamine sulfate. d. vitamin K.
b
4. About 60% of cases of acute rhinosinusitis are caused by bacterial organisms. The antibiotic of choice is: a. Augmentin. b. Amoxil. c. erythromycin. d. septra.
b
Brenda, a 64-year-old with a long-term history of smoking, recently retired from the chemical laboratory department of a large company. After months of complaining of a persistent cough, sore throat, pain, and burning in the throat, Brenda was admitted to the hospital with a diagnosis of cancer of the larynx. 3. Assessment of a patient admitted for laryngeal carcinoma includes: a. palpation of the frontal and maxillary sinuses to detect infection or inflammation. b. palpation of the neck for swelling. c. inspection of the nasal mucosa for polyps. d. all of the above techniques.
b
Jerome, a 52-year-old widower, is admitted for a laryngectomy owing to a malignant tumor. 1. Before developing a care plan, the nurse needs to know whether Jerome's voice will be preserved. The surgical procedure that would not damage the voice box is a: a. partial laryngectomy. b. supraglottic laryngectomy. c. thyrotomy. d. total laryngectomy.
b
10. During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. To care for the tracheostomy appropriately, what should the nurse do? a. Deflate the cuff, then remove and suction the inner cannula. b. Remove the inner cannula and replace it per institutional guidelines. c. Remove the inner cannula if the patient shows signs of airway obstruction. d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube.
b. An inner cannula is a second tubing that fits inside the outer tracheostomy tube. Disposable inner cannulas are frequently used but nondisposable ones can be removed and cleaned of mucus that has accumulated on the inside of the tube. Many tracheostomy tubes do not have inner cannulas because when humidification is adequate, accumulation of mucus should not occur.
13. What is included in the nursing care of the patient with a cuffed tracheostomy tube? a. Change the tube every 3 days. b. Monitor cuff pressure every 8 hours. c. Perform mouth care every 12 hours. d. Assess arterial blood gases every 8 hours.
b. Cuff pressure should be monitored every 8 hours to ensure that an air leak around the cuff does not occur and that the pressure is not too high to allow adequate tracheal capillary perfusion. Respiratory therapists in some institutions will record the cuff pressure but the nurse must be able to assess cuff pressure and identify if there is a problem maintaining cuff pressure. Tracheostomy tubes are not usually changed sooner than 7 days after a tracheotomy. Mouth care should be performed a minimum of every 8 hours and more often as needed to remove dried secretions. ABGs are not routinely assessed with tracheostomy tube placement unless symptoms of respiratory distress continue.
20. What should the nurse include in discharge teaching for the patient with a total laryngectomy? a. How to use esophageal speech to communicate b. How to use a mirror to suction the tracheostomy c. The necessity of never covering the laryngectomy stoma d. The need to use baths instead of showers for personal hygiene
b. Suctioning of the tracheostomy with the use of a mirror is a self-care activity taught to the patient before discharge. Voice rehabilitation is usually managed by a speech therapist or speech pathologist but the nurse should discuss the various types of voice rehabilitation and the advantages and disadvantages of each option. The laryngectomy stoma should be covered with a shield during showering and covered with light scarves or fabric when aspiration of foreign materials is likely
15. When obtaining a health history from a patient with possible cancer of the mouth, what would the nurse expect the patient to report? a. Long-term denture use b. Heavy tobacco and/or alcohol use c. Persistent swelling of the neck and face d. Chronic herpes simplex infections of the mouth and lips
b. The primary risk factors associated with head and neck cancers are heavy tobacco and alcohol use and family history. Chronic infections are not known to be risk factors, although cancers in patients younger than age 50 have been associated with human papillomavirus (HPV) infection. Oral cancer may cause a change in the fit of dentures but denture use is not a risk factor for oral cancer.
21. What is the most normal functioning method of speech restoration in the patient with a total laryngectomy? a. Esophageal speech b. A transesophageal puncture c. An electrolarynx held to the neck d. An electrolarynx placed in the mouth
b. Transesophageal puncture provides the most normal voice reproduction but requires a surgical fistula made between the esophagus and the trachea and possibly a valve prosthesis. Esophageal speech involves trapping air in the esophagus and releasing it to form sound but only 10% of patients can develop fluent speech with this method. The electrolarynx, whether placed in the mouth or held to the neck, allows speech that has a metallic or robotic sound.
10. Potential complications of enlarged adenoids include all of the following except: a. bronchitis. b. nasal obstruction. c. allergies. d. acute otitis media.
c
2. The nurse assesses Isabel's postoperative vital signs and checks for the most significant postoperative complication of: a. epiglottis. b. eustachian tube perforation. c. hemorrhage. d. oropharyngeal edema.
c
4. Isabel is to be discharged the same day of her tonsillectomy. The nurse makes sure that her family knows to: a. encourage her to eat a house diet to build up her resistance to infection. b. offer her only clear liquids for 3 days, to prevent pharyngeal irritation. c. offer her soft foods for several days to minimize local discomfort and supply her with necessary nutrients. d. supplement her diet with orange and lemon juices because of the need for vitamin C to heal tissues.
c
19. Following a supraglottic laryngectomy, the patient is taught how to use the supraglottic swallow to minimize the risk of aspiration. In teaching the patient about this technique, what should the nurse instruct the patient to do? a. Perform Valsalva maneuver immediately after swallowing. b. Breathe between each Valsalva maneuver and cough sequence. c. Cough after swallowing to remove food from the top of the vocal cords. d. Practice swallowing thin, watery fluids before attempting to swallow solid foods.
c. A supraglottic laryngectomy involves removal of the epiglottis and false vocal cords and the removal of the epiglottis allows food to enter the trachea. Supraglottic swallowing protects the trachea from aspiration by taking a deep breath, putting the food or fluid in the mouth, swallowing while holding the breath, coughing immediately after swallowing to remove the food from the top of the vocal cord, swallowing again, then breathing. Super-supraglottic swallowing requires performance of the Valsalva maneuver before placing food in the mouth and swallowing. See Table 27-9.
6. A patient with an acute pharyngitis is seen at the clinic with fever and severe throat pain that affects swallowing. On inspection, the throat is reddened and edematous with patchy yellow exudates. The nurse anticipates that collaborative management will include a. treatment with antibiotics. b. treatment with antifungal agents. c. a throat culture or rapid strep antigen test. d. treatment with medication only if the pharyngitis does not resolve in 3 to 4 days.
c. Although inadequately treated β-hemolytic streptococcal infections may lead to rheumatic heart disease or glomerulonephritis, antibiotic treatment is not recommended until strep infections are definitely diagnosed with culture or antigen tests. The manifestations of viral and bacterial infections are similar and appearance is not diagnostic except when the white irregular patches on the oropharynx suggest that candidiasis is present.
8. What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? a. A tracheostomy is safer to perform in an emergency. b. An ET tube has a higher risk of tracheal pressure necrosis. c. A tracheostomy tube allows for more comfort and mobility. d. An ET tube is more likely to lead to lower respiratory tract infection
c. With a tracheostomy (versus an endotracheal [ET] tube), patient comfort is increased because there is no tube in the mouth. Because the tube is more secure, mobility is improved. The ET tube is more easily inserted in an emergency situation. It is preferable to perform a tracheostomy in the operating room because it requires careful dissection but it can be performed with local anesthetic in the intensive care unit (ICU) or in an emergency. With a cuff, tracheal pressure necrosis is as much a risk with a tracheostomy tube as with an ET tube and infection is also as likely to occur because the defenses of the upper airway are bypassed.
11. To assess for an upper respiratory tract infection, the nurse should palpate: a. the frontal and maxillary sinuses. b. the trachea. c. the neck lymph nodes. d. all of the above areas.
d
14. Nursing intervention for a patient with a fractured nose includes all of the following except: a. applying cold compresses to decrease swelling and control bleeding. b. assessing respirations to detect any interference with breathing. c. observing for any clear fluid drainage from either nostril. d. packing each nostril with a cotton pledget to minimize bleeding and help maintain the shape of the nose during fracture setting.
d
19. A patient with a total laryngectomy would no longer have: a. natural vocalization. b. protection of the lower airway from foreign particles. c. a normal effective cough. d. all of the above mechanisms.
d
2. Health teaching for viral rhinitis (common cold) includes advising the patient to: a. blow his or her nose gently to prevent spread of the infection. b. blow through both nostrils to equalize the pressure. c. rest, to promote overall comfort. d. do all of the above.
d
2. Jerome is scheduled for a total laryngectomy. Preoperative education includes: a. informing him that there are ways he will be able to carry on a conversation without his voice. b. making sure that he knows he will require a permanent tracheal stoma. c. reminding him that he will not be able to sing, whistle, or laugh. d. all of the above.
d
20. Patient education for a laryngectomy includes: a. advising that large amounts of mucus can be coughed up through the stoma. b. cautioning about preventing water from entering the stoma. c. telling the patient to expect a diminished sense of taste and smell. d. doing all of the above.
d
3. Postoperative nutrition is usually maintained by way of a nasogastric catheter. The nurse needs to tell Jerome that oral feedings usually begin after: a. 24 hours. b. 2 to 3 days. c. 5 to 6 days. d. 1 week.
d
4. The nurse can advise the mother that nasal packing used to control bleeding can be left in place: a. no longer than 2 hours. b. an average of 12 hours. c. an average of 24 hours. d. anywhere from 2 to 6 days.
d
5. Nursing suggestions for a patient with acute or chronic rhinosinusitis include: a. adequate fluid intake. b. increased humidity. c. local heat applications to promote drainage. d. all of the above.
d
5. Postoperative nursing measures to promote respiratory effectiveness include: a. assisting with turning and early ambulation. b. positioning Jerome in semi- to high-Fowler's position. c. reminding Jerome to cough and take frequent deep breaths. d. all of the above.
d
7. A complication of acute pharyngitis can be: a. mastoiditis. b. otitis media. c. peritonsillar abscess. d. all of the above.
d
7. Jerome needs to know that the laryngectomy tube will be removed when: a. esophageal speech has been perfected. b. he requests that it be removed. c. oral feedings are initiated. d. the stoma is well healed.
d
8. Nursing management for a patient with acute pharyngitis includes: a. applying an ice collar for symptomatic relief of a severe sore throat. b. encouraging bed rest during the febrile stage of the illness. c. suggesting a liquid or soft diet during the acute stage of the disease. d. all of the above measures.
d
Gilberta, a 14-year-old high school student, is sent with her mother to the emergency department of a local hospital for uncontrolled epistaxis. 2. Initial nursing measures in the emergency department that can be used to stop the nasal bleeding include: a. compressing the soft outer portion of the nose against the midline septum continuously for 5 to 10 minutes. b. keeping Gilberta in the upright position with her head tilted forward to prevent swallowing and aspiration of blood. c. telling Gilberta to breathe through her mouth and to refrain from talking. d. all of the above.
d
Isabel, a 14-year-old girl, has just undergone a tonsillectomy and adenoidectomy. The staff nurse assists her with transport from the recovery area to her room. 1. On the basis of knowledge about tonsillar disease, the nurse knows that Isabel must have experienced symptoms that required surgical intervention. Clinical manifestations may have included: a. hypertrophy of the tonsils. b. repeated attacks of otitis media. c. suspected hearing loss secondary to otitis media. d. all of the above.
d
11. Which actions prevent the dislodgement of a tracheostomy tube in the first 3 days after its placement (select all that apply)? a. Provide tracheostomy care every 24 hours. b. Keep the patient in the semi-Fowler position at all times. c. Keep a same size or larger replacement tube at the bedside. d. Tracheostomy ties are not changed for 24 hours after tracheostomy procedure. e. Suction the tracheostomy tube when there is a moist cough or a decreased SpO2 . f. A physician performs the first tube change, no sooner than 7 days after the tracheostomy.
d, e, f. Changing the tracheostomy tapes or the tube too soon will be irritating to the trachea and could contribute to dislodgement of the tracheostomy tube. Suctioning should be done when increased secretions are evident in the tube to prevent the patient from severe coughing, which could cause tube dislodgement. Tracheostomy care is done every 8 hours. Keeping the patient in a semi-Fowler position will not prevent dislodgement. Keeping an extra tube at the bedside will speed reinsertion if the tracheostomy tube is dislodged but it will not prevent dislodgement.
2. Priority Decision: The nurse receives an evening report on a patient who underwent posterior nasal packing for epistaxis earlier in the day. What is the first patient assessment the nurse should make? a. Patient's temperature b. Level of the patient's pain c. Drainage on the nasal dressing d. Oxygen saturation by pulse oximetry
d. All of the assessments are appropriate but the most important is the patient's oxygen status. After the posterior nasopharynx is packed, some patients, especially older adults, experience a decrease in PaO2 and an increase in PaCO2 because of impaired respiration and the nurse should monitor the patient's respiratory rate and rhythm and SpO2 .
4. During assessment of the patient with a viral upper respiratory infection, the nurse recognizes that antibiotics may be indicated based on what finding? a. Cough and sore throat b. Copious nasal discharge c. Temperature of 100°F (38°C) d. Dyspnea and severe sinus pain
d. Dyspnea and severe sinus pain as well as tender swollen glands, severe ear pain, or significantly worsening symptoms in a patient who has a viral upper respiratory infection (URI) indicate lower respiratory involvement and a possible secondary bacterial infection. Bacterial infections are indications for antibiotic therapy but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. Low-grade elevated temperature, cough, sore throat, myalgia, and purulent nasal drainage at the end of a cold are common symptoms of viral rhinitis and influenza.
9. What are the characteristics of a fenestrated tracheostomy tube (select all that apply)? a. The cuff passively fills with air. b. Cuff pressure monitoring is not required. c. It has two tubings with one opening just above the cuff. d. Patient can speak with an attached air source with the cuff inflated. e. Airway obstruction is likely if the exact steps are not followed to produce speech. f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted.
e, f. The fenestrated tracheostomy tube has openings on the outer cannula to allow air to pass over the vocal cords to allow speaking. If the steps of using the fenestrated tracheostomy tube are not completed in the correct order, severe respiratory distress may result. The cuff of the tracheostomy tube with a foam-filled cuff passively fills with air and does require pressure monitoring, although cuff integrity must be assessed daily. The speaking tracheostomy tube has two tubes attached. One tube allows air to pass over the vocal cords to enable the person to speak with the cuff inflated.
The patient has decided to use the voice rehabilitation that offers the best speech quality even though it must be cleaned regularly. The nurse knows that this is what kind of voice rehabilitation? Electromyography Intraoral electrolarynx Neck type electrolarynx Transesophageal puncture
Transesophageal puncture
The nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to an employee. Which question should the nurse ask before administration of this vaccine? "Are you allergic to chicken?" "Could you be pregnant now?" "Did you ever have influenza?" "Have you ever had hepatitis B?"
"Could you be pregnant now?"
The nurse teaches a patient about the use of budesonide intranasal spray for seasonal allergic rhinitis. The nurse determines that medication teaching is successful if the patient makes which statement? "My liver function will be checked with blood tests every 2 to 3 months." "The medication will decrease the congestion within 3 to 5 minutes after use." "I may develop a serious infection because the medication reduces my immunity." "I will use the medication every day of the season whether I have symptoms or not."
"I will use the medication every day of the season whether I have symptoms or not."
The nurse teaches a patient with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which statement, if made by the patient, indicates further teaching is required? "I should avoid using ibuprofen for pain and discomfort." "It is important for me to take my blood pressure medication every day." "I will sit down and pinch the tip of my nose for at least 10 to 15 minutes." "If I get a nosebleed, I will lie down flat and raise my feet above my heart."
"If I get a nosebleed, I will lie down flat and raise my feet above my heart."
5. A 36-year-old patient with type 1 diabetes mellitus asks the nurse whether an influenza vaccine is necessary every year. What is the best response by the nurse? a. "You should get the trivalent inactivated influenza vaccine that is injected every year." b. "Only health care workers in contact with high-risk patients should be immunized each year." c. "An annual vaccination is not necessary because previous immunity will protect you for several years." d. "Antiviral drugs, such as zanamivir (Relenza), eliminate the need for vaccine except in the older adult."
. a. The injected trivalent inactivated influenza vaccine is recommended for individuals 6 months of age and older and those at increased risk for influenza-related complications, such as people with chronic medical conditions or those who are immunocompromised, residents of long-term care facilities, health care workers, and providers of care to at-risk persons. The live attenuated influenza vaccine is given intranasally and is recommended for all healthy people between the ages of 2 and 49 but not for those at increased risk of complications or health care providers. The immunity will not protect for several years, as new strains of influenza may develop each year. Antiviral agents will help to reduce the duration and severity of influenza in those at high risk but immunization is the best control.
3. What does the nurse teach the patient with intermittent allergic rhinitis is the most effective way to decrease allergic symptoms? a. Undergo weekly immunotherapy. b. Identify and avoid triggers of the allergic reaction. c. Use cromolyn nasal spray prophylactically year-round. d. Use over-the-counter antihistamines and decongestants during an acute attack.
. b. The most important factor in managing allergic rhinitis is identification and avoidance of triggers of the allergic reactions. Immunotherapy may be indicated if specific allergens are identified and cannot be avoided. Drug therapy is an alternative to avoidance of the allergens but long-term use of decongestants can cause rebound nasal congestion.
3. Which information should the nurse teach the client diagnosed with acute sinusitis? 1. Instruct the client to complete all the ordered antibiotics. 2. Teach the client how to irrigate the nasal passages. 3. Have the client demonstrate how to blow the nose. 4. Give the client samples of a narcotic analgesic for the headache.
1. The client should be taught to take all antibiotics as ordered. Discontinuing antibiotics prior to the full dose results in the development of antibioticresistant bacteria. Sinus infections are difficult to treat and may become chronic, and will then require several weeks of therapy or possibly surgery to control
688. The nurse is caring for a client with a diagnosis of influenza who first began to experience symptoms yesterday. Antiviral therapy is prescribed and the nurse provides instructions to the client about the therapy. Which statement by the client indicates an understanding of the instructions? 1. "I must take the medication exactly as prescribed." 2. "Once I start the medication, I will no longer be contagious." 3. "I will not get any colds or infections while taking this medication." 4. "This medication has minimal side effects and I can return to normal activities."
1 Rationale: Antiviral medications for influenza must be taken exactly as prescribed. These medications do not prevent the spread of influenza and clients are usually contagious for up to 2 days after the initiation of antiviral medications. Secondary bacterial infections may occur despite antiviral treatment. Side effects occur with these medications and may necessitate change in activities, especially when driving or operating machinery if dizziness occurs.
12. The nurse is caring for a client diagnosed with a cold. Which is an example of an alternative therapy? 1. Vitamin C, 2,000 mg daily. 2. Strict bedrest. 3. Humidification of the air. 4. Decongestant therapy.
1. Alternative therapies are therapies not accepted as standard medical practice. These may be encouraged as long as they do not interfere with the medical regimen. Vitamin C in large doses is thought to improve the immune system's functions.
67. The charge nurse is assigning clients for the shift. Which client should be assigned to the new graduate nurse? 1. The client diagnosed with cancer of the lung who has chest tubes. 2. The client diagnosed with laryngeal spasms who has stridor. 3. The client diagnosed with laryngeal cancer who has multiple fistulas. 4. The client who is two (2) hours post-partial laryngectomy.
1. Chest tubes are part of the nursing education curriculum. The new graduate should be capable of caring for this client or at least knowing when to get assistance.
5. The client diagnosed with tonsillitis is scheduled to have surgery in the morning. Which assessment data should the nurse notify the health-care provider about prior to surgery? 1. The client has a hemoglobin of 12.2 g/dL and hematocrit of 36.5%. 2. The client has an oral temperature of 100.2˚F and a dry cough. 3. There are one (1) to two (2) white blood cells in the urinalysis. 4. The client's current international normalized ratio (INR) is 1.0.
2. A low-grade temperature and a cough could indicate the presence of an infection, in which case the health-care provider would not want to subject the client to anesthesia and the possibility of further complications. The surgery would be postponed.
11. Which task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Feed a client who is postoperative tonsillectomy the first meal of clear liquids. 2. Encourage the client diagnosed with a cold to drink a glass of orange juice. 3. Obtain a throat culture on a client diagnosed with bacterial pharyngitis. 4. Escort the client diagnosed with laryngitis outside to smoke a cigarette.
2. Clients with colds are encouraged to drink 2,000 mL of liquids a day. The UAP could do this.
69. The male client has had a radial neck dissection for cancer of the larynx. Which action by the client indicates a disturbance in body image? 1. The client requests a consultation by the speech therapist. 2. The client has a towel placed over the mirror. 3. The client is attempting to shave himself. 4. The client practices neck and shoulder exercises.
2. Placing a towel over the mirror indicates the client is having difficulty looking at his reflection, a body-image problem.
9. The client diagnosed with influenza A is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicates an understanding of this prescription? 1. "These pills will make me feel better fast and I can return to work." 2. "The antibiotics will help prevent me from developing a bacterial pneumonia." 3. "If I had gotten this prescription sooner, I could have prevented this illness." 4. "I need to take these pills until I feel better; then I can stop taking the rest."
2. Secondary bacterial infections often accompany influenza, and antibiotics are often prescribed to help prevent the development of a bacterial infection.
72. The client who has undergone a radical neck dissection and tracheostomy for cancer of the larynx is being discharged. Which discharge instructions should the nurse teach? Select all that apply. 1. The client will be able to speak again after the surgery area has healed. 2. The client should wear a protective covering over the stoma when showering. 3. The client should clean the stoma and then apply a petroleum-based ointment. 4. The client should use a humidifier in the room. 5. The client can get a special telephone for communication.
2. The client breathes through a stoma in the neck. Care should be taken not to allow water to enter the stoma.
63. The client is three (3) days post-partial laryngectomy. Which type of nutrition should the nurse offer the client? 1. Total parenteral nutrition. 2. Soft, regular diet. 3. Partial parenteral nutrition. 4. Clear liquid diet.
2. The client should be eating normal foods by this time. The consistency should be soft to allow for less chewing of the food and easier swallowing because a portion of the throat musculature has been removed. The client should be taught to turn the head toward the affected side when swallowing to help prevent aspiration.
676. A client has a prescription to take guaifenesin (Mucinex). The nurse determines that the client understands the proper administration of this medication if the client states that he or she will: 1. Take an extra dose if fever develops. 2. Take the medication with meals only. 3. Take the tablet with a full glass of water. 4. Decrease the amount of daily fluid intake.
3 Rationale: Guaifenesin (Mucinex) is an expectorant and should be taken with a full glass of water to decrease the viscosity of secretions. Extra doses should not be taken. The client should contact the physician if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache. Fluids are needed to decrease the viscosity of secretions. The medication does not have to be taken with meals.
1. The home health-care nurse is talking on the telephone to a male client diagnosed with hypertension and hears the client sneezing. The client tells the nurse he has been blowing his nose frequently. Which question should the nurse ask the client? 1. "Have you had the flu shot in the last two (2) weeks?" 2. "Are there any small children in the home?" 3. "Are you taking over-the-counter medicine for these symptoms?" 4. "Do you have any cold sores associated with your sneezing?"
3. A client diagnosed with hypertension should not take many of the over-thecounter medications because they work by causing vasoconstriction, which will increase the hypertension.
61. The nurse is admitting a client with a diagnosis of rule-out cancer of the larynx. Which information should the nurse teach? 1. Demonstrate the proper method of gargling with normal saline. 2. Perform voice exercises for 30 minutes three (3) times a day. 3. Explain that a lighted instrument will be placed in the throat to biopsy the area. 4. Teach the client to self-examine the larynx monthly.
3. A laryngoscopy will be performed to allow for visualization of the vocal cords and to obtain a biopsy for pathological diagnosis.
4. The client has been diagnosed with chronic sinusitis. Which sign/symptom alerts the nurse to a potentially life-threatening complication? 1. Muscle weakness. 2. Purulent sputum. 3. Nuchal rigidity. 4. Intermittent loss of muscle control.
3. Nuchal rigidity is a sign/symptom of meningitis, which is a life-threatening potential complication of sinusitis resulting from the close proximity of the sinus cavities to the meninges.
68. The nurse is writing a care plan for a client newly diagnosed with cancer of the larynx. Which problem is the highest priority? 1. Wound infection. 2. Hemorrhage. 3. Respiratory distress. 4. Knowledge deficit.
3. Respiratory distress is the highest priority. Hemorrhaging and infection are serious problems, but airway is priority.
65. The client has had a total laryngectomy. Which referral is specific for this surgery? 1. CanSurmount. 2. Dialogue. 3. Lost Chord Club. 4. SmokEnders.
3. The Lost Chord Club is an American Cancer Society-sponsored group of survivors of larynx cancer. These clients are able to discuss the feelings and needs of clients who have had laryngectomies because they have all had this particular surgery
8. The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)? 1. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday and has moderate pain. 2. The six (6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who will not swallow medication. 3. The 18-year-old client who had a Caldwell-Luc procedure three (3) days ago and has purulent drainage on the drip pad. 4. The 45-year-old client diagnosed with a peritonsillar abscess who requires IVPB antibiotic therapy four (4) times a day.
3. The postoperative client with purulent drainage could be developing an infection. The experienced nurse would be needed to assess and monitor the client's condition.
10. The nurse is developing a plan of care for a client diagnosed with laryngitis and identifies the client problem "altered communication." Which intervention should the nurse implement? 1. Instruct the client to drink a mixture of brandy and honey several times a day. 2. Encourage the client to whisper instead of trying to speak at a normal level. 3. Provide the client with a blank note pad for writing any communication. 4. Explain that the client's aphonia may become a permanent condition.
3. Voice rest is encouraged for the client experiencing laryngitis
2. The school nurse is presenting a class to students at a primary school on how to prevent the transmission of the common cold virus. Which information should the nurse discuss? 1. Instruct the children to always keep a tissue or handkerchief with them. 2. Explain that children current with immunizations will not get a cold. 3. Tell the children they should go to the doctor if they get a cold. 4. Demonstrate to the students how to wash hands correctly.
4. Hand washing is the single most useful technique for prevention of disease.
7. The client diagnosed with chronic sinusitis who has undergone a Caldwell-Luc procedure is complaining of pain. Which intervention should the nurse implement first? 1. Administer the narcotic analgesic IVP. 2. Perform gentle oral hygiene. 3. Place the client in semi-Fowler's position. 4. Assess the client's pain.
4. Prior to intervening, the nurse must assess to determine the amount of pain and possible complications occurring that could be masked if narcotic medication is administered.
64. The nurse is preparing the client diagnosed with laryngeal cancer for a laryngectomy in the morning. Which intervention is the nurse's priority? 1. Take the client to the intensive care unit for a visit. 2. Explain that the client will need to ask for pain medication. 3. Demonstrate the use of an antiembolism hose. 4. Find out if the client can read and write.
4. The client is having the vocal cords removed and will be unable to speak. Communication is a high priority for this client. If the client is able to read and write, a Magic Slate or pad of paper should be provided. If the client is illiterate, the nurse and the client should develop a method of communication using pictures.
71. The client diagnosed with cancer of the larynx has had four (4) weeks of radiation therapy to the neck. The client is complaining of severe pain when swallowing. Which scientific rationale explains the pain? 1. The cancer has grown to obstruct the esophagus. 2. The treatments are working on the cancer and the throat is edematous. 3. Cancers are painful and this is expected. 4. The treatments are also affecting the esophagus, causing ulcerations.
4. The esophagus is extremely radiosensitive, and esophageal ulcerations are common. The pain can become so severe the client cannot swallow saliva. This is a situation in which the client will be admitted to the hospital for IV narcotic pain medication and possibly total parenteral nutrition.
When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment? Patient comfort Airway patency Incisional drainage Blood pressure and heart rate
Airway patency
The nurse is reviewing the health history of a patient with laryngeal cancer. Which finding would the nurse expect? Family history of lung cancer Recent inhalation of noxious fumes Frequent straining of the vocal cords Chronic use of alcohol and tobacco products
Chronic use of alcohol and tobacco products
A patient with a history of tonsillitis reports difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? Bilateral erythema of especially large tonsils Temperature 102.2° F, diaphoresis, and chills Contraction of neck muscles during inspiration β-Hemolytic streptococcus in the throat culture
Contraction of neck muscles during inspiration
A school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus? (Select all that apply.) Cover the nose when coughing. Obtain an influenza vaccination. Stay at home when symptomatic. Drink noncaffeinated fluids daily. Obtain antibiotic therapy promptly.
Cover the nose when coughing. Obtain an influenza vaccination. Stay at home when symptomatic.
The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect to teach the patient about? Nasal packing Epistaxis balloon Gastrostomy tube Peripheral skin care
Gastrostomy tube
The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident? Age older than 80 years History of upper respiratory infections Chronic obstructive pulmonary disease (COPD) History of a severe allergic reaction to the vaccine
History of a severe allergic reaction to the vaccine
A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement? Apply an external splint to the nose. Insert plastic nasal implant surgically. Humidify the air for mouth breathing. Maintain surgical packing in the nose.
Maintain surgical packing in the nose.
A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when the tracheostomy tube is expelled by coughing. What is the priority action by the nurse? Suction the tracheostomy opening. Maintain the airway with a sterile hemostat. Use an Ambu bag and mask to ventilate the patient. Insert the tracheostomy tube obturator into the stoma.
Maintain the airway with a sterile hemostat.
The patient seeks relief from the symptoms of an upper respiratory infection (URI) lasting for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis? Coughing Fever, chills Dust allergy Maxillary pain
Maxillary pain
A patient is admitted for joint replacement surgery and has a permanent tracheostomy. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Suction the tracheostomy. Check stoma site for skin breakdown. Complete tracheostomy care using sterile technique. Provide oral care with a toothbrush and tonsil suction tube.
Provide oral care with a toothbrush and tonsil suction tube.
A patient has a tracheostomy tube after reconstructive surgery for invasive head and neck cancer. What is most important for the nurse to assess before performing tracheostomy cannula care? Level of consciousness Quality of breath sounds Presence of the gag reflex Tracheostomy cuff pressure
Quality of breath sounds
The nurse is caring for a patient with a tracheostomy. What is the priority nursing assessment for this patient? Electrolyte levels and daily weights Assessment of speech and swallowing Respiratory rate and oxygen saturation Pain assessment and assessment of mobility
Respiratory rate and oxygen saturation
Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? Assessing the need for suctioning Suctioning the patient's oropharynx Assessing the patient's swallowing ability Maintaining appropriate cuff inflation pressure
Suctioning the patient's oropharynx
The nurse observes clear nasal drainage in a patient newly admitted with facial trauma with a nasal fracture. What is the nurse's priority action? Test the drainage for the presence of glucose. Suction the nose to maintain airway clearance. Document the findings and continue monitoring. Apply a drip pad and reassure the patient this is normal.
Test the drainage for the presence of glucose.
A patient is being discharged from the emergency department after being treated for epistaxis. In teaching first aid measures in the event the epistaxis would recur, what measures should the nurse suggest? (Select all that apply.) Tilt patient's head backwards. Apply ice compresses to the nose. Tilt head forward while sitting upright. Pinch the entire soft lower portion of the nose. Lying down until 15 minutes after the bleeding ceases
Tilt head forward while sitting upright. Pinch the entire soft lower portion of the nose.
1. Nursing measures associated with the uncomplicated common cold include all of the following except: a. administering prescribed antibiotics to decrease the severity of the viral infection. b. informing the patient about the symptoms of secondary infection, the major complication of a cold. c. suggesting adequate fluid intake and rest. d. teaching people that the virus is contagious for 2 days before symptoms appear and during the first part of the symptomatic phase.
a
12. To assess for an upper respiratory tract infection, the nurse should inspect: a. the nasal mucosa. b. the frontal sinuses. c. the tracheal mucosa. d. all of the above.
a
13. Airway clearance in a patient with an upper airway infection is facilitated by all of the following except: a. decreasing systemic hydration. b. humidifying inspired room air. c. positional drainage of the affected area. d. administering prescribed vasoconstrictive medications.
a
18. An early sign of cancer of the larynx in the glottic area (66% of cases) is: a. affected voice sounds. b. burning of the throat when hot liquids are ingested. c. enlarged cervical nodes. d. dysphagia.
a
3. Acyclovir, an antiviral agent, is recommended for: a. herpes simplex infection. b. rhinitis. c. sinusitis. d. bronchitis.
a
3. The nurse maintains Isabel in the recommended postoperative position of: a. prone with her head on a pillow and turned to the side. b. reverse Trendelenburg with the neck extended. c. semi-Fowler's position with the neck flexed. d. supine with her neck hyperextended and supported with a pillow.
a
6. Acute pharyngitis of a bacterial nature is most commonly caused by: a. group A, beta-hemolytic streptococci. b. gram-negative Klebsiella. c. Pseudomonas. d. Staphylococcus aureus.
a
9. The most common bacterial pathogen associated with tonsillitis and adenoiditis is: a. group A, beta-hemolytic streptococcus. b. gram-negative Klebsiella. c. Pseudomonas. d. Staphylococcus aureus.
a
