Chapter 10: Fluid and Electrolytes
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?
20mL or less
Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?
Ensure
The 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? a) interference with sinus drainage b) excessive protein c) increased exposure to health care environment d) more than 8 hours of sleep per night
a) interference with sinus drainage
The nurse assesses a client who has a nasogastric tube for long-term nutritional needs for complications associated with the medical device. The nurse monitors the client for _________a________ a, finding indicative ________b__________
a; purulent nasal drainage b; rhinosinitus
Which is the antibiotic of choice used to treat acute bacterial rhinosinitus?
amoxicillin
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 the lung sounds
The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care? a) Encourage oral nutrition on the second postoperative day b) Maintain the client in low fowler's position c) develop an alternate method of communication d) Assess the tracheostomy cuff for leaks
c) develop an alternative method of communication
Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require?
emotional support
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 nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?
impaired verbal communication
A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client:
sleep with the head of bead elevated
A nurse is responsible for monitoring indicators of potential complications after laryngectomy. Which indicators would be priority concerns?
somnolence and hypotension tachycardia and tachypnea impaired swallowing persistent high tracheostomy cuff pressure
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
total laryngectomy
