Med Surg Prep U Chapter 22

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

ineffective airway clearance

A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about?

amoxicillin-clavulanic

A 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 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

Which clinical manifestation of hemorrhage is related to carotid artery rupture?

increased pulse rate

The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs?

initiate enteral feedings

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

apply direct continuous pressure

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

Drainage is less than 30 ml/day for 2 consecutive days

The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client?

avoid sports activities for 6 weeks

Which of the following interventions would be helpful for a client reporting nasal congestion, sneezing, sore throat, and muscle aches? Select all that apply.

Provide warm salt-water gargles. Administer oral ibuprofen. Teach the client about handwashing. Recommend guaifenesin.

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?

hypercapnia

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

Most cases of acute pharyngitis are caused by which of the following?

viral infection

The nurse is assessing a patient who smokes 2 packs of cigarettes per day and has a strong family history of cancer. What early sign of cancer of the larynx does the nurse look for in this patient?

affected voice sounds

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

swimming

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is

Ineffective airway clearance related to excess mucus production

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

The nurse is educating a patient diagnosed with acute bacterial rhinosinusitis about interventions that may assist with symptom control. What should the nurse include in this information? (Select all that apply.)

Ensure an adequate fluid intake. Apply local heat to promote drainage. Increase the humidity in the home.

The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

noisy breathing

You are caring for a client who is 42-years-old and status post adenoidectomy. You find the client in respiratory distress when you enter their room. 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

A patient prescribed a medication for hypertension started taking it 3 days ago and arrives in the emergency department with an edematous face and tongue and having a difficult time speaking. What medication is the nurse aware of that may produce this type of side effect?

enalapril (vasotec)

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

amoxicillin

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

amoxicillin-clavulanic acid

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

sleep with the head of bed elevated

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

I was chewing ice chips all day long

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

bleeding

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

continuous positive airway pressure CPAP

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 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

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

sinus aspirates

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

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

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

total laryngectomy

Which intervention regarding nutrition is implemented for clients who have undergone laryngectomy?

use enteral feedings after the procedure

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

hoarseness

Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has?

laryngeal cancer

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

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

Your client is status post total laryngectomy and cannot talk. What intervention should you make to help this client communicate?

provide alternative methods of communication

The nurse at an employee wellness clinic is meeting with a client who reports voice hoarseness for more than 2 weeks. To determine if the client may have symptoms of early laryngeal cancer, the next question the nurse should ask is, "Do you have

a persistent cough or sore throat

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

The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care?

apply an ice pack

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 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