Ch 18 Management of Patients with Upper Respiratory Tract Disorders

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 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 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 caring for a client following a tonsillectomy and adenoidectomy. Two hours after the procedure, the client begins to vomit large amounts of dark blood at frequent intervals and is tachycardic and febrile. After notifying the surgeon, the nurse

obtains a light, mirror, gauze, and curved hemostats.

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

sit upright, leaning slightly forward.

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 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

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.

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."

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.

- Check for any unusual changes in breathing during the first 48 hours. - Observe for any clear drainage from either nostril. - Elevate the head of the bed for sleeping during the first week. - Restrict from sports activities for 6 weeks.

The client is to receive cephalexin (Ancef) 500 mg in 50 mL of normal saline intravenous piggyback. The medication is to infuse over 30 minutes. How many mL/hr would the nurse set the intravenous pump? Enter the correct number ONLY.

100

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

2 to 12 days

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

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.

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

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

Apply direct continuous pressure.

A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis?

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 epistaxis. The nurse should prepare to assist the physician with what tasks?

Applying nasal packing

The nurse is caring for 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 with acute viral rhinosinusitis is being seen in a clinic. The nurse is providing discharge instructions and includes the following information:

Avoid air travel.

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.

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.

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

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

The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect?

Edema of the upper airway

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

Emotional support

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

Epistaxis

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

The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?

Hoarseness for 2 weeks

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

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

A permanent tracheal stoma would be necessary.

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

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

Ineffective airway clearance

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

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.

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

Noisy breathing

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 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

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

The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?

Sudden restlessness

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

Viral infection

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

laryngeal cancer