Management of Patients With Upper Respiratory Tract Disorders

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 induration

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

I was chewing ice chips all day long

A client is postoperative for a partial laryngectomy following a diagnosed malignancy. The client is to start oral feedings. The nurse does the following interventions:

Obtains results of a swallow study Provides thick liquids

A patient has had a larygectomy 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

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 nurse is caring for a client with a new tracheostomy. Which of the following nursing diagnoses are priorities? Select all that apply.

Ineffective airway clearance related to increased secretions Impaired gas exchange related to shallow breathing and anxiousness

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 nurse is assessing a client for obstructive sleep apnea (OSA). Which are signs and symptoms of OSA? Select all that apply.

Polysythemia Loud snoring Insomnia

In adults, bone marrow is usually aspirated from which area?

Posterior iliac crest

A client has a nursing diagnosis of ineffective airway clearance related to excessive mucus production. The best short-term goal is for the client to

Report decreased congestion

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

A client who has an altered level of consciousness is receiving a tube feeding. Clients receiving tube feeding should be placed in which position?

Semi-fowler's or higher

Which diagnostic test is used to confirm the diagnosis of maxillary and frontal sinusitis?

Sinus aspirates

A nurse providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client:

Sleep with the head of the bed elevated

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

A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy?

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

The nurse is an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would the nurse be sure to include in the workshop? Select all that apply

Alcohol Tobacco Industrial pollutants

A client comes into the Emergency Department with epitaxis. What intervention should you perform when caring for a client with epitaxis?

Apply direct continuous pressure

A client comes into the emergency room with epitaxis. What intervention should the nuse perform when caring for a client with epitaxis?

Apply direct continuous pressure

A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epitaxis. The nurse should prepare to assist the physician with what task?

Applying nasal packing

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?

Bleeding

A client reports feeling tired, cold, and short of breath at times. Assessment reveals tachycardia and reduced energy. What would the nurse expect the physician to order?

CBC

Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?

Continuous positive airway pressure

You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis?

Encourage deep breathing every 2 hours

Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?

Ensure mouth breathing

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

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

A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin (coumadin). THe nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching?

I'll eat four servings of fresh, dark green vegetables every day

A female client with the beta-thalassemia traits plans to marry a man of Italian ancestry who also has the trait. Which client statement indicates that she understands the teaching provided by the nurse?

I'll see a genetic counselor before starting a family

Select the nursing diagnosis that would warrant immediate health care provider notification

Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation

Select the nursing diagnosis that would warrant immediate health care provider notification.

Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation

A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever and dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may predispose the client to sinusitis?

Interference with sinus drainage

A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

Keep the stoma moist

A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for:

Nuchal rigidity

A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?

Obtain the pain medication ad delay the bath and position change until the medication reaches its peak

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 larygectomy

A client reports nasal congestion, sneezing, sore throat, and muscle aches. The nurse intervenes how? Select all that apply

Provide warm salt-water gargles Administer oral ibuprofen (Motrin) Teach the client about handwashing Recommend guaifenesin (Mucinex)

A patient with an advanced laryngeal tumor is to have radiation therapy. The patient tells the nurse, "If I am going to have radiation, I won't need surgery." What is the best response by the nurse?

Radiation is used to shrink the tumor size and is an adjunct to surgery

The nurse assesses a patient for possible acute pharyngitis. Which of the following clinical manifestations are consistent with this diagnoses. Select all that apply.

Red pharyngeal membranes Swollen lymphoid follicles White-purple exudates on the back of the throat A temperature >100.4 F

A client has a nursing diagnosis of acute pain related to the upper airway irritation. The best short-term goal for this client is for the client to

Report relief of pain to level 3 and using pen intensity scale of 1 to 10

When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided

Swimming

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

The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose?

Transillumination of the sinus

The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drain will most likely be removed?

When the patient has less than 30 ml for 2 consecutive days

The nurse is caring for a client with allergic rhinitis. The client asks the nurse about measures to help decrease allergic symptoms. Which is the best response by the nurse?

You should try to reduce exposure to irritants and allergens

When client has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the client very carefully because of the highrisk for

carotid artery hemorrhage

The nurse assesses a client who is bleeding profusely from the nose.. The nurse documents this findings as which condition?

epitaxis

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

impaired verbal communication

The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid

swimming

A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell his client about an endotracheal tube?

The ET will maintain your airway while you're under anesthesia.

Once the patient has been cleared for oral feedings, post laryngectomy, the nurse knows to prepare:

Thick liquids that are easy to swallow

The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?

Total laryngectomy

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

A client is being assessed for acute laryngitis. The nurse knows that the medical manifestations of acute laryngitis include

hourseness

An older male client with a history of chronic laryngitis reports a persistent hoarseness. The nurse is aware that this client may be at risk for which condition?

laryngeal cancer

Stiffness of the neck or inability to bend the neck is referred to as

nuchal rigidity

An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by period of breathing cessation for:

10 seconds with 5 episodes/hour

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of

2 to 12 days

The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?

A face mask

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

A permanent tracheal stoma would be necessary

Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)?

Amoxicillin

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

Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process due to thrombocytopenia in a client with leukemia?

Applying prolonged pressure to needle sites or other sources of external bleeding

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to larygenal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply

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

A nurse caring for a client who has hemophilia is getting ready to take the client's vital signs. What should the nurse do before taking a blood pressure?

Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints.

A nurse cares for a client with anemia requiring nutritional supplementation. Which nursing intervention best promotes with adherence for the prescribed therapy?

Assist the client to incorporate the therapeutic regimen into daily activities.

The nurse is caring the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Auscultate lung sounds

A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to

Check the clear fluid for glucose

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

Cocaine use

What client would be most in need of an endotracheal tube?

Comatose clients

Malignancy of the larynx can be devastating diagnosis. What does client with a diagnosis of laryngeal cancer require?

Emotional support

The nurse is caring for a client diagnosed with rhinosinusitis. The physician has ordered th eclient ot recieve four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the client that a common side effect of this medication is

Epitaxis

The client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?

Family members should continue to talk to the client

A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymphnodes. The client also reports malaise and sore throat. The nurse needs to assess first for"

Fever

A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?

Group A, beta-hemolytic streptococci

A nurse is providing discharge teaching for a client who had a layngectomy. Which instruction should the nurse include in her teaching?

Cover the stoma whenever you shower or bathe

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

Develop an alternate method of communication

When caring for a client who has just had a total larygectomy, the nurse should plan to:

Develop an alternative communication method

Which initial intervention should a nurse perform for a client with external bleeding?

Direct pressure

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 client seeks 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?

Wound drains, inserted during the laryngectomy, stay in place until what criteria are met?

Drainage of <30 mL/day for 2 consecutive days.

You are caring for a client who is 42-years-old and status post adenoidectomy. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect?

Edema of the upper airway