PNE 105 Chapter 20: Caring for Clients with Upper Respiratory Disorders. Prep U.

A client has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the client asks, "Does this kind of cancer tend to spread to other parts of the body?" What is the nurse's best response?

"This cancer usually does not spread to distant sites in the body." Explanation: The incidence of distant metastasis with squamous cell carcinoma of the head and neck (including larynx cancer) is relatively low. The client's prognosis is determined by the oncologist, but the client has asked a general question and it would be inappropriate to refuse a response. The nurse must not downplay the client's concerns.

A 13-year-old boy has been brought to the emergency department by his mother after he took a powerful blow to his nose during a volleyball game. Preliminary examination suggests a nasal fracture, which should prompt the nurse to:

Apply ice and tell the patient to keep his head elevated Rationale: Immediately after the fracture, the nurse applies ice and encourages the patient to keep the head elevated. Saline lavage, warm compresses, and nebulizers are not common treatment modalities for nasal fractures.

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. Rationale: 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.

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

Nuchal rigidity. Explanation: 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 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 Rationale: 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.

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. Explanation: 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.

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." Explanation: 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. Gently gargling with warm saline or an alkaline mouthwash assists in removing thick mucus.

A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority?

Administer one intramuscular injection of penicillin. Rationale: If a nurse is concerned that a client may not perform follow-up treatment for streptococcal pharyngitis, the highest priority is to administer penicillin as a one-time injection dose. Oral penicillin is as effective and less painful, but the client needs to take the full course of treatment to prevent antibiotic-resistant germs from developing. The nurse should provide oral and written instructions for the client, but this is not as high a priority as administering the penicillin. Having a homeless friend monitor the client's care does not ensure that the client will follow therapy.

A client stops breathing during sleep as a result of repetitive upper airway obstruction. To help decrease the frequency of the apneic episodes, the nurse intervenes by informing the client to:

Eliminate alcohol ingestion. Rationale: The client's symptoms are consistent with obstructive sleep apnea. Initial treatment includes avoidance of alcohol and hypnotic medications. Clients are told to not sleep on their backs. Administration of nasal oxygen may help with hypoxemia but has little effect on the frequency of apnea.

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 Explanation: 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.

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 Explanation: 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.

A has entered the postanesthesia care unit following sinus surgery. What will the nurse monitor closely during the postoperative period?

Repeated swallowing. Rationale: Standards of postoperative care for clients who have undergone a sinus surgery include frequent assessment to make an early detection of repeated swallowing because this could indicate a possible hemorrhage. Septal hematoma may occur with a nasal fracture. cerebrospinal fluid drainage is generally a concern related a nasal fracture but not to sinus surgery. Periorbital edema is a possible complication of surgery to repair a nasal fracture.

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. Explanation: 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.

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

Swimming. Explanation: The nurse provides the client and family with the following postoperative instructions: water should not enter the stoma because it will flow from the trachea to the lungs. Therefore, the nurse instructs the client to avoid swimming and to use a handheld shower device when bathing. The nurse also suggests that the client wear a scarf over the stoma to make the opening less obvious. The nurse encourages the client to cough every 2 hours to promote effective gas exchange.

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?

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

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

Hoarseness. Explanation: Signs of acute laryngitis include hoarseness or aphonia and severe cough. Other signs of acute laryngitis include a dry cough, and a sore throat that feels worse in the morning. If allergies are present, the uvula will be visibly edematous.

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. Explanation: The client's signs and symptoms are consistent with a fracture of the nose. Clear fluid draining from either nostril suggests leakage of cerebrospinal fluid. This can be checked by assessing for glucose, which is in cerebrospinal fluid. This finding is important to identify, because infection can be transmitted through the opening in the cribriform plate. Other options, such as applying an ice pack to the nose and administering ibuprofen, are appropriate interventions but not most important for this client. Reassuring the client that the nose is not fractured is premature until all assessments are completed.

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. Rationale: 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 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." Explanation: 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.

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. Explanation: 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 conducting a presurgical interview for a client with laryngeal cancer. The client states that he drinks approximately 20 oz. (600 mL) of vodka per day. It is imperative that the nurse inform the surgical team so the client can be assessed for what?

Delirium tremens Rationale: Considering the known risk factors for cancer of the larynx, it is essential to assess the client's history of alcohol intake. Infection is a risk in the postoperative period, but not an appropriate answer based on the client's history. Depression and nonadherence are risks in the postoperative phase, but would not be critical short-term assessments.

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?" Explanation: 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 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." Rationale: 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.

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." Rationale: 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." Rationale: 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 college student has sought care at the campus medical clinical after a 5-day history of malaise that he believes is due to a bad cold. Which of the student's following statements should cause the nurse to suspect an alternative diagnosis?

"I've been burning up with a fever at night and then getting terrible chills too." Rationale: Rhinitis, headache, pruritus, and sneezing are all characteristic signs and symptoms of the viral rhinitis. However, fever is less common and is usually low-grade when it exists.

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." Rationale: 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 evaluate the client before surgery and establish a method of immediate postoperative communication.

A college student presents to the health clinical with signs and symptoms of viral rhinitis (common cold). The patient states, "I've felt terrible all week; what can I do to feel better?" Which of the following is the best response the nurse can give?

"You should rest, increase your fluids, and take Ibuprofen." Explanation: Management of viral rhinitis consists of symptomatic therapy that includes adequate fluid intake, rest, prevention of chilling, and use of expectorants as needed. Warm saltwater gargles soothe the sore throat, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, relieve aches and pains. Antibiotics are not prescribed because they do not affect the virus causing the patient's signs and symptoms. Topical nasal decongestants should be used with caution. The symptoms of viral rhinitis may last from 1 to 2 weeks.

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." Explanation: The nurse instructs the client with allergic rhinitis to avoid or reduce exposure to allergens and irritants, such as dusts, molds, animals, fumes, odors, powders, sprays, and tobacco smoke. Receiving an influenza vaccination each year is recommended for clients with infectious rhinitis. To prevent possible drug interactions, the client is cautioned to read drug labels before taking any over-the-counter medication. Clients with nasal septal deformities or nasal polyps may be referred to an ear, nose, and throat specialist.

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 periods of breathing cessation for:

10 seconds with 5 episodes/hour. Rationale: OSA is characterized by frequent and loud snoring, with breathing cessation for 10 seconds or longer, for at least five episodes per hour, followed by abrupt awakening with a loud snort as the blood oxygen level drops. Symptoms typically progress with weight gain, aging, and during the transition to menopause for women.

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. Explanation: 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.

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

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

Cuff pressure on the endotracheal or tracheostomy tube should be monitored by the nurse at least every:

8 hours. Explanation: Cuff pressure must be monitored at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique.

A nurse practitioner has provided care for three different clients with chronic pharyngitis over the past several months. Which clients are at greatest risk for developing chronic pharyngitis?

A client who is a habitual user of alcohol and tobacco. Rationale: Chronic pharyngitis is common in adults who live and work in dusty surroundings, use the voice to excess, suffer from chronic chough, and habitually use alcohol and tobacco. Caffeine and spicy foods have not been linked to chronic pharyngitis. GERD is not a noted risk factor.

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. Rationale: 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 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. Rationale: 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. Explanation: 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.

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. Rationale: 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. Affected voice sounds are not always early signs of subglottic or supraglottic cancer, however. The patient may complain of a persistent cough or sore throat and pain and burning in the throat, especially when consuming hot liquids or citrus juices. A lump may be felt in the neck. Later symptoms include dysphagia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath.

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

Amoxicillin-clavulanic acid. Explanation: 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 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 acid. Rationale: Treatment of acute rhinosinusitis depends on the cause; a 5- to 7-day course of antibiotics is prescribed for bacterial cases. Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid ( Augmentin) is the antibiotic of choice. 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 organisms that are now more commonly implicated in ABRS.

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. Rationale: 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.

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

Answer: a, b, c, d a. Provide warm salt-water gargles. b. Administer oral ibuprofen. c. Teach the client about handwashing. d. Refer the client to a physician for antibiotic therapy. Rationale: Described signs and symptoms are consistent with viral rhinitis (the common cold). Management consists of symptomatic therapy, such as gargling with warm salt-water gargles, taking nonsteroidal anti-inflammatory medications (e.g., ibuprofen [Motrin]), and using guaifenesin (Mucinex), which promotes removal of secretions. Handwashing is the most effective measure to prevent transmission of organisms. Antibiotics should not be used, because they are not effective against viruses and misuse of antibiotics have contributed to the development of antibiotic-resistant organisms.

The nurse is educating the patient diagnosed with acute pharyngitis on methods to alleviate discomfort. What interventions should the nurse include in the information? (Select all that apply.)

Answer: a, b, d a. Apply an ice collar. b. Stay on bed rest during the febrile stage of the illness. d. Try a liquid or soft diet during the acute stage of the disease. Explanation: A liquid or soft diet is provided during the acute stage of the disease, depending on the patient's appetite and the degree of discomfort that occurs with swallowing. Cool beverages, warm liquids, and flavored frozen desserts such as ice pops are often soothing. The nurse instructs the patient to stay in bed during the febrile stage of illness and to rest frequently once up and about. Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. An ice collar also can relieve severe sore throats.

The nurse is performing a nutritional assessment on a client who has been diagnosed with cancer of the larynx. Which laboratory values would be assessed when determining the nutritional status of the client? Select all that apply.

Answer: b, c, e b. Protein level c. Albumin level e. Glucose level Explanation: The nurse also assesses the client's general state of nutrition, including height and weight and body mass index, and reviews laboratory values that assist in determining the client's nutritional status (albumin, protein, glucose, and electrolyte levels). The white blood cell count and the platelet count would not normally assist in determining the client's nutritional status.

A 13-year-old soccer player presents to the emergency room with a fractured nose. The patient's mother is given which of the following post-discharge instructions? Select all that apply.

Answer: b, c, e, f b. Check for any unusual changes in breathing during the first 48 hours. c. Observe for any clear drainage from either nostril. e. Elevate the head of the bed for sleeping during the first week. f. Restrict from sports activities for 6 weeks. Rationale: Ice or cold compresses are applied four to six times a day, for several days, until the swelling is decreased. Packing is inserted to control bleeding. It would not be used to reshape the nose.

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. Explanation: Following a nasal 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. The packing inserted to stop the bleeding may be uncomfortable and unpleasant, and obstruction of the nasal passages by the packing forces the client to breathe through the mouth. This, in turn, causes the oral mucous membranes to become dry. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. Applying direct pressure is not indicated in this situation.

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. Rationale: Following a nasal 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. The packing inserted to stop the bleeding may be uncomfortable and unpleasant, and obstruction of the nasal passages by the packing forces the client to breathe through the mouth. This, in turn, causes the oral mucous membranes to become dry. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. Applying direct pressure is not indicated in this situation.

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. Explanation: 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.

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 Explanation: 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.

The nurse is to make a room assignment for a client diagnosed with an upper respiratory infection. The other clients with empty beds in the room are listed in the accompanying chart. The best room assignment for the new client would be with Client:

B (Patient who is receiving IV infusions of crystalloid solution following epistaxis). Explanation: The nurse needs to make the appropriate room assignment based on the client's problems, safety, and risk for infection to others. The client with an upper respiratory infection may transmit infection to susceptible people. Clients A, C, and D have increased susceptibility for infection because of immunosuppression or surgery.

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

Bleeding. Explanation: 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.

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, Explanation: 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.

The health care provider has ordered continuous positive airway pressure (CPAP) with the delivery of oxygenation. The patient asks the nurse what the benefit of CPAP is. What would be the nurse's best response?

CPAP prevents the collapse of the patient's airway. Rationale: CPAP provides positive pressure to the airways throughout the respiratory cycle preventing collapse. It does not eliminate the need for supplementary oxygen or alter perfusion.

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. Rationale: The client's signs and symptoms are consistent with a fracture of the nose. Clear fluid draining from either nostril suggests leakage of cerebrospinal fluid. This can be checked by assessing for glucose, which is in cerebrospinal fluid. This finding is important to identify, because infection can be transmitted through the opening in the cribriform plate. Other options, such as applying an ice pack to the nose and administering ibuprofen, are appropriate interventions but not most important for this client. Reassuring the client that the nose is not fractured is premature until all assessments are completed.

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. Explanation: 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.

A 60-year-old man has been diagnosed with obstructive sleep apnea (OSA) based on his clinical symptoms and polysomnographic findings. What intervention should the nurse perform to assist this patient in the management of his health problem?

Encouraging the patient to avoid alcohol and hypnotic medications. Rationale: Treatments for OSA are varied but include weight loss and avoidance of alcohol and hypnotic medications initially. Patients are not normally able to awaken themselves during apneic periods. Deep breathing exercises and changes to sleeping times are not known to improve the signs and symptoms of OSA.

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. Explanation: 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.

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. Explanation: 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 breathing through the mouth. The nurse applies an ice pack to reduce pain and swelling and not a warm pack. The nurse recommends the use of a splint and the application of pressure to the convex portion of the nose in case of a nasal fracture.

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

Fever Rationale: The signs and symptoms described are consistent with acute pharyngitis. The nurse needs to assess for a fever higher than 39.3°C. Findings will help to determine if the client requires antibiotic therapy. The client may also experience headache, myalgias, and nausea. The nurse needs to assess for these symptoms also, and symptomatic treatment would then be provided.

A client's total laryngectomy has created a need for alaryngeal speech which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the client when teaching him about this process?

Fitting for a voice prosthesis. Rationale: In clients receiving tracheoesophageal puncture, a valve is placed in the tracheal stoma to divert air into the esophagus and out the mouth. Once the puncture is surgically created and has healed, a voice prosthesis (Blom-Singer®) is fitted over the puncture site. A nasogastric tube and belching are not required. An artificial pharynx is not used.

A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes:

Gastroesophageal reflux disease (GERD). Explanation: The nurse should ask whether the client has a medical history of GERD. Laryngitis is common in older adults and may be secondary to GERD. Older adults are more likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. COPD, CHF, and RF are not associated with laryngitis in the older adult.

A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes:

Gastroesophageal reflux disease (GERD). Rationale: The nurse should ask whether the client has a medical history of GERD. Laryngitis is common in older adults and may be secondary to GERD. Older adults are more likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. COPD, CHF, and RF are not associated with laryngitis in the older adult.

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 Rationale: Viral infection causes most cases of acute pharyngitis. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus. Bacterial infection accounts for the remainder of cases. Ten percent of adults with pharyngitis have group A beta-hemolytic streptococcus (GABHS), which is commonly referred to as group A streptococcus (GAS) or streptococcal pharyngitis.

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. Explanation: 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.

The perioperative nurse has admitted a client who has just underwent a tonsillectomy. The nurse's postoperative assessment should prioritize which of the following potential complications of this surgery?

Hemorrhage Rationale: Hemorrhage is a potential complication of a tonsillectomy. Increased pulse, fever, and restlessness may indicate a postoperative hemorrhage. Difficulty ambulating and bradycardia are not common complications in a client after a tonsillectomy. Infrequent swallowing does not indicate hemorrhage; frequent swallowing does.

The nurse is caring for a client whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer?

Hoarseness Explanation: Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.

The nurse is caring for a patient in the outpatient clinic with suspicion of cancer due to recent weight loss for unidentifiable reasons. The patient has a 25-year history of smoking. The nurse performs an assessment and asks the patient about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer?

Hoarseness Explanation: Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.

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. Rationale: 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.

The nurse is caring for a client in the ED for epistaxis. What information should the nurse include in client discharge teaching as a way to prevent epistaxis?

Humidify the indoor environment. Rationale: Discharge teaching for prevention of epistaxis should include the following: avoid forceful nose bleeding, straining, high altitudes, and nasal trauma (nose picking). Adequate humidification may prevent drying of the nasal passages. Keeping nasal passages clear and using a tissue when blowing the nose are not included in discharge teaching for the prevention of epistaxis. Decongestants are not indicated.

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

Impaired verbal communication. Rationale: 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.

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. Rationale: 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.

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. Rationale: For a patient diagnosed with acute sinusitis, the nurse should instruct the patient that hot packs, increasing fluid intake, and elevating the head of the bed can promote drainage.

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

Ineffective airway clearance Explanation: 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. Rationale: Each of the listed diagnoses is valid, but ineffective airway clearance is the priority nursing diagnosis for all conditions.

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. Explanation: The principal causes are the spread of an infection from the nasal passages to the sinuses and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis because trapped secretions readily become infected. Client with persistent sinus infections may have allergies, nasal polyps, or a deviated septum. Eating a well-balanced diet that includes but does not rely exclusively on protein is a measure that may help reduce incidences of sinusitis. Getting plenty of rest is a measure that may help reduce incidences of sinusitis. Increased exposure to the health care environment is not a specific cause of sinusitis, which is more commonly caused by allergies or blockage of the nasal passages.

The nurse is caring for a client who needs education on his medication therapy for allergic rhinitis. The client is to take Cromolyn daily. In providing education for this client, how should the nurse describe the action of the medication?

It inhibits the release of histamine and other chemicals. Rationale: Cromolyn inhibits the release of histamine and other chemicals. It is prescribed to treat allergic rhinitis. Beta-adrenergic agents lead to bronchodilation and stimulate beta-2 adrenergic receptors in the smooth muscle of the bronchi and bronchioles. It does not affect proton pump action or the sodium-potassium pump in the nasal cells.

A young client presents with symptoms of sniffling, nasal discharge, coughing, and sneezing. The symptoms which are keeping the client awake at night, and interrupting feedings. The client is diagnosed with rhinovirus. How many strains of this virus cause coryza?

More than 100. Rationale: Rhinitis is inflammation of the nasal mucous membranes. It also is referred to as the common cold or coryza. Rhinitis may be acute, chronic, or allergic, depending on the cause. The most common cause is the rhinovirus, of which more than 100 strains exist.

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

Nuchal rigidity. Explanation: 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.

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. Explanation: 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.

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. Explanation: 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 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. Rationale: 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. Rationale: 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 client comes to the ED and is admitted with epistaxis. Pressure has been applied to the client's midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using what treatment to control the bleeding?

Silver nitrate application. Rationale: If pressure to the midline septum does not stop the bleeding for epistaxis, additional treatment of silver nitrate application, Gelfoam, electrocautery, or vasoconstrictors may be used. Suction may be used to visualize the nasal septum, but it does not alleviate the bleeding. Irrigation with a hypertonic solution is not used to treat epistaxis.

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

Sit upright, leaning slightly forward. Rationale: 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 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. Explanation: 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.

A nursing student is discussing a client with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for clients with viral pharyngitis?

Symptom management is the main focus of medical and nursing care. Explanation: Nursing care for clients with viral pharyngitis focuses on symptomatic management. Antibiotics are not prescribed for viral etiologies. Surgery is not indicated in the treatment of viral pharyngitis. Chronic hoarseness is not a common sequela of viral pharyngitis, so teaching ways to prevent it would be of no use in this instance.

A female patient with obstructive sleep apnea (OSA) has been recommended a continuous positive airway pressure (CPAP) machine for the treatment of her health problem. The nurse's priority for patient education should be:

The importance of complying with CPAP despite the inconvenience associated with its use. Explanation: Although CPAP is effective in management of OSA, patient compliance with the treatment continues to be a major concern. Nursing interventions aimed at increasing compliance are consequently a priority. Steroids, bronchodilators, and pulse oximetry are not normally necessary. Daily exercise is beneficial but the promotion of compliance is a priority for patients using CPAP.

A patient comes to the clinic complaining of a possible upper respiratory infection. What should the nurse inspect that would indicate that an upper respiratory infection may be present?

The nasal mucosa. Rationale: The nurse inspects the nasal mucosa for abnormal findings such as increased redness, swelling, exudate, and nasal polyps, which may develop in chronic rhinitis. The mucosa of the nasal turbinates may also be swollen (boggy) and pale bluish-gray. The nurse palpates the frontal and maxillary sinuses for tenderness, which suggests inflammation, and then inspects the throat by having the patient open the mouth wide and take a deep breath.

The nurse is caring for a client with a severe nosebleed. The physician inserts a nasal sponge. What should the nurse teach the client about this intervention?

The sponge can stay in place for 3 to 4 days if needed. Explanation: A compressed nasal sponge may be used. Once the sponge becomes saturated with blood or is moistened with a small amount of saline, it will expand and produce tamponade to halt the bleeding. The packing may remain in place for 48 hours or up to 3 or 4 days if necessary to control bleeding. This does not require the client to be supine or to avoid all NSAIDs. Packing does not increase the risk for sinusitis.

Two months prior to a scheduled tonsillectomy, a client has a peritonsillar abscess related to a severe strep infection. After culturing the area and before receiving the results, the physician immediately prescribes a potent antibiotic. The physician is quick to prescribe a strong antibiotic to prevent:

The spread of microorganisms into the bloodstream. Explanation: Immediate treatment of a peritonsillar abscess is recommended to prevent the spread of the causative microorganism to the bloodstream or adjacent structures. Hemoptysis is the expectoration of bloody sputum and not a specific concern with a peritonsillar abscess. This client has already been scheduled for a tonsillectomy. Hypertrophied turbinates are enlargements of the nasal conchae, which results from chronic rhinitis and eventually leads to sinusitis.

A client states that her family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to what factor?

The virus is shed for 2 days prior to the emergence of symptoms. Explanation: Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. Antibiotic resistance is not relevant to viral illnesses and OTC medications do not have a "rebound" effect. Genetic factors do not exist.

The nurse is creating a care plan for a client who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. What form of alaryngeal communication will likely be chosen?

Tracheoesophageal puncture Explanation: Tracheoesophageal puncture is simple and has few complications. It is associated with high phonation success, good phonation quality, and steady long-term results. As a result, it is preferred over esophageal speech, an electric larynx or ASL.

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

Use enteral feedings after the procedure Explanation: Enteral feedings are used 10 to 14 days after a laryngectomy to avoid irritation to the sutures and reduce the risk of aspiration. When oral intake resumes, the nurse offers small amounts of thick liquids. Following a laryngectomy, the client may experience anorexia related to a diminished sense of taste and smell. Excess zinc can impair the immune system and lower the levels of high-density lipoproteins ("good" cholesterol). Therefore, long-term or ongoing use of zinc lozenges to prevent a cold is not recommended.

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. Rationale: 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. Explanation: 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 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. Explanation: 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.

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. Explanation: 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.

The nurse in a long-term-care facility is aware of the importance of preventing upper respiratory infections (URIs) among the residents of the facility. How is this best accomplished?

Vigilant handwashing by staff and residents. Explanation: Thorough handwashing is the mainstay of URI prevention. Nutritious diet, high fluid intake, and the use of decongestants may be necessary treatments for residents who have URIs, but none of these measures appreciably protects against the development of URIs.

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. Explanation: Wound drains, inserted during surgery, may be in place to assist in removal of fluid and air from the surgical site. Suction also may be used, but cautiously, to avoid trauma to the surgical site and incision. The nurse observes, measures, and records drainage. When drainage is less than 30 mL/day for 2 consecutive days, the physician usually removes the drains.