IG: Chap 31 - Upper Respiratory

Which statement indicates that the client needs more teaching regarding responses to rhinoplasty? a. "I will take my temperature twice each day and report any fever to my doctor." b. "I will wait until next month to have my photograph taken, after all the swelling is gone." c. "I will take acetaminophen instead of aspirin for pain to avoid excessive bleeding." d. "I will drink at least 3 quarts of liquids a day and use a stool softener."

ANS: B Explain that edema and bruising may last for weeks and that the final surgical result will be evident in 6 to 12 months. The client should take his or her temperature and report fever in case of infection. The client should take acetaminophen because there is less risk of bleeding than with aspirin. Fluids and stool softeners will decrease the risk of straining.

Which statement indicates that the client does not understand teaching about radiation therapy for laryngeal cancer? a. "I will avoid exposing my skin to sunlight during treatment." b. "I will purchase a wig so that my appearance will be close to normal." c. "I will rest my voice and communicate by writing for the next 2 months." d. "I will not shave until all the redness and peeling of the skin on my face and neck is gone."

ANS: B Hair loss should not occur from undergoing radiation therapy for laryngeal cancer. The client should stay out of the sun during treatment, because the skin can become severely burned. Resting the voice is recommended during treatment. The client should also avoid shaving until redness and peeling of facial and neck skin are diminished.

Which client requires immediate nursing intervention? a. Client with shortness of breath b. Client with sternal retraction c. Client with pulse oximetry reading of 95% d. Client with crackles bilaterally

ANS: B The client with sternal retraction is experiencing serious respiratory difficulty. Although the client may exhibit shortness of breath as well as bilateral crackles, neither of these symptoms shows the same degree of respiratory difficulty being experienced as sternal retraction. A pulse oximetry reading of 95% is within normal limits.

What intervention is essential in the care of a client post-radical neck dissection? a. Applying direct pressure to the carotid artery with a gloved hand b. Keeping the carotid artery and the dressing wet with sterile saline c. Maintaining the stability of the position of the laryngectomy tube d. Assessing the adequacy of blood flow by Doppler every 2 hours

ANS: B Wound breakdown is a common complication caused by poor nutrition, a long smoking history, alcohol use, wound contamination, and previous radiation therapy. Manage wound breakdown with packing and local care as prescribed to keep the wound clean and stimulate the growth of healthy granulation tissue. None of the other options are interventions applicable to a life-threatening situation such as a carotid artery rupture. Applying pressure to the carotid artery, maintaining the positioning of the laryngectomy tube, and assessing blood flow by Doppler will all be ineffective at preventing rupture of the carotid artery.

The client has undergone rhinoplasty. Which assessment finding would require immediate intervention on the part of the nurse? a. Swelling and bruising around the area b. A change in nasal breathing c. Repeated swallowing d. Frequent blowing of the nose

ANS: C After rhinoplasty, repeated swallowing may indicate that the client is experiencing posterior nasal bleeding. Immediate intervention is necessary to prevent hemorrhaging. Swelling and bruising are common after the surgery and would not indicate nasal bleeding. The client cannot breathe through the nose after surgery because the nares are packed and taped. The client would also not be able to blow the nose.

Which clinical manifestation in a client 4 hours status post-nasoseptoplasty will the nurse report immediately to the surgeon? a. Mouth breathing b. Swelling and bruising of eyes c. Repeated swallowing d. Packing saturated with pink serous drainage

ANS: C Repeated swallowing may indicate posterior nasal bleeding and should be reported immediately. The nurse should examine the back of the client's throat to confirm the presence of blood. The client would be expected to be breathing through the mouth because the nasal passages are packed with gauze. Bruising and swelling around the eyes would be expected. The packing in the nares would be expected to collect pink and serous drainage. Bright red drainage would be cause for concern.

Which client is at greatest risk for development of obstructive sleep apnea? a. A woman who is 8 months pregnant b. A middle-aged man with gastroesophageal reflux disease c. A middle-aged woman who is 50 pounds overweight d. An older man with type 2 diabetes and a history of sinus infections

ANS: C The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.

Which statement indicates that the client needs more teaching about nasal continuous positive airway pressure therapy for obstructive sleep apnea? a. "This device should also decrease my snoring." b. "I am also going to lose weight to help this problem." c. "I will use this machine whenever I sleep in bed, regardless of the time of day." d. "I will make certain that no one smokes in the room when I use the machine."

ANS: D Having others in the room avoid smoking will not be of the same priority as the other instructions. It is much more accurate for the client to understand that continuous positive airway pressure therapy will assist in decreasing snoring and weight loss. The machine should be used whenever the client sleeps in bed, regardless of time of day.

What will the nurse teach the client who is being discharged after a fixed centric occlusion for a mandibular fracture? a. Keep wire cutters readily available at the bedside. b. Eat at least six soft or liquid meals each day. c. Use an irrigating device for oral care four times daily. d. Sleep in a semi-Fowler's position for 1 week postoperatively.

ANS: A Instruct the client to keep wire cutters with him or her at all times in case this emergency arises. This is the only option that would be life-threatening if allowed to occur. Although the client will need to sleep in a semi-Fowler's position to assist in avoiding aspiration if vomiting occurs, this will not be as high a priority as having wire cutters available. The client will probably be ordered a liquid diet and may also be ordered an irrigating device for oral care, but these are not the priority interventions.

The client has undergone a partial laryngectomy and has received instructions on the supraglottic method of swallowing. Which is the nurse's highest priority action? a. Reinforcing the teaching by placing a chart in the client's room detailing the steps in the process b. Evaluating the effectiveness of the teaching by ordering a dynamic swallow study c. Emphasizing the important points of the teaching by repeating the instruction weekly d. Asking the client to demonstrate swallowing with the nurse present

ANS: A The client who is status post-partial laryngectomy should be taught alternate methods of swallowing and a chart to reinforce teaching should be placed in the client's room. A dynamic swallow study is performed to guide rehabilitation for swallowing. Repeating the steps each week is not as effective as showing the client a chart. Having the client demonstrate swallowing will not verify that he or she understands supraglottic swallowing correctly.

Which is the priority assessment for the client who has undergone posterior nasal packing 1 hour ago for a posterior nosebleed? a. Assessing adequacy of the client's airway b. Examining posterior pharynx for evidence of bleeding c. Checking oral mucous membranes for excessive dryness d. Asking the client to rate the pain experience on a scale of 1 to 10

ANS: A The client's airway could be compromised by bleeding and is the highest priority assessment. If the client were to have posterior nasal bleeding, she or he could quickly loose a lot of blood. The second highest priority assessment would be assessing for evidence of bleeding. If the oral mucous membranes were dry, this would not indicate an emergency situation. Pain assessment is a priority, but not as high as an assessment of the airway.

The client preparing to go home after a radical neck dissection for cancer is crying. When the nurse asks why he is crying, the client writes, "I know I shouldn't cry. This surgery may have saved my life, but I can't believe how much my appearance has changed." What is the nurse's best response? a. "It's all right to cry. Mourning this loss is important in getting past this point." b. "You're right. It is silly to carry on like this when the surgery may cure you." c. "Would you like to talk to someone who also has had a laryngectomy?" d. "How have you coped with difficult situations in the past?"

ANS: A The many changes resulting from a laryngectomy influence physical, social, and emotional functioning. Clients may perceive changes in their quality of life. The client needs to grieve. The nurse would never tell the client that her or his actions are "silly." Once the client moves through the grieving process, it may be appropriate for him or her to talk to someone who is further along in the grieving process.

Which intervention is the nurse's highest priority when encouraging self-care for a client with a closed fracture of the nose? a. Advising the client not to eat or drink for at least 24 hours after sustaining the fracture b. Teaching the client how to apply cold compresses to the area to reduce swelling c. Urging the client to sleep without a pillow to hasten resolution of the swelling d. Reassuring the client that his or her appearance will normalize after the swelling has resolved

ANS: B After a closed fracture of the nose, the nurse will encourage rest and the use of cool compresses on the nose, eyes, or face to help reduce swelling and bruising. Avoiding eating or drinking and sleeping without a pillow will not hasten resolution of the swelling. Reassuring the client regarding his or her appearance is not included in self-care.

Which client statement indicates potential obstructive sleep apnea? a. "I have so much trouble getting to sleep at night." b. "I wake up feeling just as tired as I did when I went to bed." c. "I wake up persistently during the night, over and over." d. "I can't breathe when I lie flat in the bed."

ANS: B Clients are often unaware that they have sleep apnea. The disorder should be suspected for any person who has persistent daytime sleepiness or complains of waking up tired. Clients with this problem do not usually have trouble getting to sleep, nor do they remember waking up during the night. Although they may snore heavily, they do not usually complain of an inability to breathe while lying flat in bed.

The client is brought to the emergency department with severe facial trauma. Which is the nurse's highest priority in caring for this client? a. Assessing for a skull fracture b. Assessing for a patent airway c. Controlling facial swelling d. Preserving vision

ANS: B In prioritizing care, airway is the first priority. Assessments for fractures would be a secondary priority, as would controlling swelling. Although preserving vision will be an important concern, the only selection that involves airway, breathing, or circulation is assessment for a patent airway.

Which is the nurse's best action to prevent aspiration in a client with open vocal cord paralysis? a. Teach the client to tilt his or her head back as far as possible when swallowing. b. Teach the client to tuck his or her chin down and forehead forward when swallowing. c. Teach the client to breath slowly and deeply while swallowing. d. Teach the client to keep his or her head very still and straight while swallowing.

ANS: B The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration.

The client who is scheduled to have a vertical laryngectomy asks the nurse what changes to expect in voice quality after the surgery. What is the nurse's best response? a. "You will not be able to speak above a whisper." b. "Your permanent voice will be hoarse and breathy." c. "The removal of your larynx results in permanent loss of natural speech." d. "Speech will return to normal within 6 months."

ANS: B The client's voice will be permanently affected after this type of a procedure. The client will be able to speak above a whisper. However, the voice will be hoarse. Speech will not be completely lost, but it will not be normal.

Which client can the nurse delegate to the LPN/LVN who has been pulled to the unit? a. Young adult who is 6 hours postoperative radical neck dissection b. Older adult client with esophageal cancer who is awaiting gastric tube placement c. Older adult client who is status post-laryngectomy and is awaiting discharge teaching d. Middle-aged client who is awaiting preoperative teaching for laryngeal cancer

ANS: B The nurse can delegate stable clients to an LPN who has been pulled to the unit. The client who is 6 hours postoperative should not be delegated because he or she is not stable. The client who needs discharge teaching cannot be cared for by the LPN because the RN is the one responsible for the teaching and this cannot be delegated to an LPN. Similarly, the client who needs preoperative teaching needs to have this done by the RN.

Which statement made by the client who is prescribed "voice rest" therapy for vocal cord polyps indicates the need for more teaching? a. "I will stay out of rooms and places where people are smoking." b. "When I speak at all, I will whisper rather than use a normal tone of voice." c. "For the next several weeks, I will not lift anything weighing more than 10 pounds." d. "I will drink at least 3 quarts of water each day and use stool softeners."

ANS: B Treatment for vocal cord polyps includes not speaking, no lifting, and no smoking. The client has to be educated not to even whisper when resting the voice. It is also appropriate for the client to stay out of rooms where people are smoking, and to stay hydrated and use stool softeners.

Which discharge instructions will the nurse give to the client for laryngectomy stoma care? a. "Gently wash the stoma with soap and water and then apply a water-based lubricant." b. "Use cotton-tipped applicators to clean out the stoma at least twice daily." c. "Use a syringe to irrigate the stoma with a solution of sterile normal saline and peroxide." d. "Gently scrape crusts from the stoma opening. Apply petroleum jelly externally."

ANS: A The client is taught to wash the stoma gently and prevent anything from getting into the opening. The client should never scrape around the opening because this could cause broken skin, irritation, and infection.

Which clinical manifestation in a client with paralysis of one vocal cord alerts the nurse to the possibility of aspiration? a. The client's oxygen saturation is decreased. b. The client's voice is breathy and weak. c. The client coughs immediately after swallowing. d. The client has an audible wheeze on exhalation.

ANS: C The client with open vocal cord paralysis is at risk for aspiration because the airway may not close during swallowing. Coughing may indicate that the client's airway is irritated from aspirated contents. Decreased oxygen saturation can occur for any number of reasons. A breathy and weak voice may indicate weak muscles and wheezing may indicate swelling or inflammation in the airways.