Chapter 20: Caring for Clients with Upper Respiratory Disorders

What is the most commonly prescribed treatment for the common cold?

Antihistamines Antihistamines are the first group of medications recommended for treating sneezing, pruritus, rhinorrhea, and nasal congestion associated with the common cold.

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.

How many upper respiratory infections would a person of average health expect to have each year?

3 to 5 The average person experiences three to five upper respiratory infections each year.

A client is scheduled for vocal cord stripping to treat a vocal cord lesion. Which statement indicates that the client has realistic postoperative expectations for this surgery?

"I know my voice will sound hoarse." Following vocal cord stripping, the client's voice will be hoarse. The affected cord is stripped of mucosa but otherwise left intact following vocal cord stripping.

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." 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.

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." 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.

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." 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 evalua

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 client has just undergone surgery for a nasal obstruction. Which intervention should the nurse perform to promote the client's safety and recuperation?

Ensure mouth breathing. 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 mouth breathing. The client should be instructed to avoid contact with nose or surrounding tissue postsurgery. A splint would not be necessary following this surgery. The application of an ice pack will reduce pain and swelling.

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 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.

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.

It is cold season and the school nurse been asked to provide an educational event for the parent teacher organization of the local elementary school. What should the nurse include in teaching about the treatment of pharyngitis?

Use of warm saline gargles or throat irrigations can relieve symptoms. Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. The benefits of this treatment depend on the degree of heat that is applied. The nurse teaches about these procedures and about the recommended temperature of the solution: high enough to be effective and as warm as the client can tolerate, usually 105ºF to 110ºF (40.6ºC to 43.3ºC). Irrigating the throat may reduce spasm in the pharyngeal muscles and relieve soreness of the throat. You would not tell the parent teacher organization that there is no real treatment of pharyngitis.

A 42-year-old client is admitted to the ED after an assault. The client received blunt trauma to the face and has a suspected nasal fracture. What intervention should the nurse perform?

Apply ice and keep the client's head elevated. Immediately after the 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. Dependent positioning would exacerbate bleeding and the nose is not irrigated. Occlusive dressings are not used.

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

Cocaine use 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.

The nurse is creating a plan of care for a client diagnosed with acute laryngitis. What intervention should be included in the client's plan of care?

Encourage the client to limit speech whenever possible. Management of acute laryngitis includes resting the voice, avoiding irritants (including smoking), resting, and inhaling cool steam or an aerosol. Fluid intake should be increased. Warm washcloths on the throat will not help relieve the symptoms of acute laryngitis.

The nurse is doing discharge teaching in the ED with a client who had a nosebleed. What should the nurse include in the discharge teaching of this client?

In case of recurrence, apply direct pressure for 15 minutes. The nurse explains how to apply direct pressure to the nose with the thumb and the index finger for 15 minutes in case of a recurrent nosebleed. If recurrent bleeding cannot be stopped, the client is instructed to seek additional medical attention. ASA is not contraindicated in most cases and the client should avoid blowing the nose for an extended period of time, not just 45 minutes.

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

Penicillin The 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 now used more often and are as effective as and less painful than injections. Penicillin injections are recommended only if there is a concern that the client will not comply with therapy. Robitussin DM may be used as an antitussive. Aspirin or Tylenol, or Tylenol with codeine, may be given for severe sore throats.

The nurse is performing preoperative teaching with a client who has cancer of the larynx. After explaining the most important information, what is the nurse's best action?

Provide the client with audiovisual materials about the surgery. Informational materials (written and audiovisual) about the surgery are given to the client and family for review and reinforcement. The nurse never gives personal contact information to the client. Nothing in the scenario indicates that a referral to a social worker or psychologist is necessary. False reassurance must always be avoided.

The nurse is teaching a client with allergic rhinitis about the safe and effective use of his medications. What would be the most essential information to give this client about preventing possible drug interactions?

Read drug labels carefully before taking OTC medications. Client education is essential when assisting the client in the use of all medications. To prevent possible drug interactions, the client is cautioned to read drug labels before taking any OTC medications. Some websites are reliable and valid information sources, but this is not always the case. Clients do not necessarily need to limit themselves to one pharmacy, though checking for potential interactions is important. Not all OTC medications are safe additions to prescription medication regimens.

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 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.

The nurse is providing care for a client who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize?

The client's airway patency The client with a laryngectomy is a risk for airway occlusion and respiratory distress. As in all nursing situations, assessment of the airway is a priority over other potential complications and assessment parameters.

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.

A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is

amoxicillin-clavulanic acid. Amoxicillin-clavulanic acid (Augmentin) is the antibiotic of choice to treat ABRS. For patients who are allergic to penicillin, doxycycline (Vibramycin) or respiratory quinolones such as levofloxacin (Levaquin) or moxifloxacin (Avelox) can be used. Other antibiotics prescribed previously to treat ABRS, including cephalosporins such as cephalexin (Keflex), cefuroxime (Ceftin), cefaclor (Ceclor), and cefixime (Suprax), trimethoprim-sulfamethoxazole (Bactrim, Septra), and macrolides such as clarithromycin (Biaxin) and azithromycin (Zithromax), are no longer recommended because they are not effective in treating antibiotic-resistant organism

A client has been admitted to the hospital unit after having a peritonsillar abscess drained. The nurse assesses the client for which signs of respiratory obstruction? Select all that apply.

dyspnea restlessness Following surgery, the nurse encourages the client to drink fluids and closely monitors the client for signs of respiratory obstruction such as dyspnea, restlessness, or cyanosis.

Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?

impaired verbal communication 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.

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

sit upright, leaning slightly forward. 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.

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." 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 aerosol 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 is recovering from a tonsillectomy in the postanesthesia care unit. After an overnight stay in the hospital due to increased secretions and vomiting, the nurse delivers client education and accompanying paperwork. Which comment indicates that the client requires additional education?

"If I'm vomiting, I'll drink lemon-lime soda to keep myself hydrated." Instruct the client to avoid carbonated fluids and fluids high in citrus content. Such fluids are caustic to the surgical site and may traumatize tissue, disrupting the suture line. Instruct the client not to cough, clear throat, blow nose, or use a straw in the first few postoperative days. These actions increase pressure on the suture line and may cause disruption and bleeding. Keeping the head elevated may help prevent bleeding. Gentl

A client is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the client's nutrition during treatment?

A liquid or soft diet A liquid or soft diet is provided during the acute stage of the disease, depending on the client's appetite and the degree of discomfort that occurs with swallowing. The client is encouraged to drink as much fluid as possible (at least 2 to 3 L/day). There is no need for increased potassium or protein intake.

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

A permanent tracheal stoma would be necessary. 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.

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 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.

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

The nurse is caring for a client who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment?

Assessment of swallowing ability A common postoperative complication from this type of surgery is difficulty in swallowing, which creates a potential for aspiration. Cardiovascular complications are less likely at this stage of recovery. The client's body image should be assessed, but dysphagia has the potential to affect the client's airway, and is a consequent priority.

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.

Which of the following nursing interventions should a nurse perform when caring for a patient with an endotracheal tube?

Clean teeth with applicators The nurse should suction the oropharynx and the mouth as needed and clean the teeth with applicators. The nurse does not suction the patient's nose. Humidification is necessary to keep the inspired air moist. Restraining the patient may be necessary because the patient may attempt to remove or pull the tube.

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 of more than 2 week's 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.

A client visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the client to perform what action?

Increase fluid intake. For a client diagnosed with acute sinusitis, the nurse should instruct the client that hot packs, increasing fluid intake, and elevating the head of the bed can promote drainage. Applying heat will not promote sinus drainage. Postural drainage is used to remove bronchial secretions.

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

Ineffective airway clearance 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.

The nurse is planning the care of a client who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis?

Ineffective airway clearance related to airway alterations Each of the listed diagnoses is valid, but ineffective airway clearance is the priority nursing diagnosis for all conditions.

The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk?

Keep a complete suction setup at the bedside. Due to the risk for aspiration, the nurse keeps a suction setup available in the hospital and instructs the family to do so at home for use if needed. TPN is not indicated and small meals do not necessarily reduce the risk of aspiration. Physical therapists do not address swallowing ability.

The nurse is explaining the safe and effective administration of nasal spray to a client with seasonal allergies. What information is most important to include in this teaching?

Overuse of nasal spray may cause rebound congestion. The use of topical decongestants is controversial because of the potential for a rebound effect. The client should hold his or her head back for maximal distribution of the spray. Only the client should use the bottle.

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 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.

The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a client who is postoperative day 1 following total laryngectomy. What is the nurse's best action?

Rapidly assess the client and notify the surgeon about the client's bleeding. The nurse promptly notifies the surgeon of any active bleeding, which can occur at a variety of sites, including the surgical site, drains, and trachea. The drain should not be removed or connected to suction. Supine positioning would exacerbate the bleeding. Vitamin K would not be given without an order.

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 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.

Which of the following should a nurse assess in a patient who has undergone a sinus surgery?

Repeated swallowing The nurse specifies standards of postoperative care for patients who have undergone a sinus surgery. The nurse observes the patient for repeated swallowing. This helps detect possible hemorrhage. Septal hematoma is used to detect a nasal fracture. Periorbital edema is assessed postoperatively in case of a nasal fracture. Colorless and clear cerebrospinal fluid may drain from the nares in severe nasal fractures.

A client has had a laryngectomy as treatment for laryngeal cancer. Which nutritional interventions should be implemented for the client?

Use enteral feedings after the procedure. Enteral feedings are used for 10 to 14 days after a laryngectomy to avoid irritation to the sutures and reduce the risk of aspiration.

A nurse is suctioning the tracheostomy of a hospitalized client with laryngeal cancer. Which nursing action should be included in this client's plan of care?

Use intermittent suctioning while slowly withdrawing and rotating the catheter. The nurse suctions the client to remove secretions that can obstruct the airway. Begin intermittent suctioning while slowly withdrawing and rotating the catheter. Do not suction for more than 10 seconds at a time. It is important to avoid unnecessary suctioning to decrease trauma to the airway. Allow the client to rest and breathe deeply before repeating if more suctioning is necessary.

A client has had a laryngectomy as treatment for laryngeal cancer. Which postoperative instruction is of utmost importance to the client's health and safety?

avoid swimming Water should not enter the stoma because it will flow from the trachea to the lungs.

A client has had four major nosebleeds in one day. The physician performs a physical exam and orders blood tests. The client has no history of hypertension, trauma, or cocaine use. What could be the cause of nosebleeds that are so difficult to control?

blood dyscrasias Causes of nosebleed include trauma, rheumatic fever, infection, hypertension, nasal tumors, and blood dyscrasias. Epistaxis that results from hypertension or blood dyscrasias is likely to be severe and difficult to control.

An older male client with a history of chronic laryngitis reports a persistent hoarseness. What condition is the client at risk to develop?

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 women. The client's history of chronic laryngitis may also predispose the client 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. Coryza is another term for the common cold. Symptoms include sneezing, sore throat, and nasal congestion. Clients with a peritonsillar abscess experience difficulty and pain with swallowing, fever, malaise, ear pain, and difficulty talking.