Chapter 22: Management of Patients with Upper Respiratory Tract Disorders

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? Plugged tracheostomy tube Infection Post operative bleeding Edema of the upper airway

Edema of the upper airway Explanation: An endotracheal tube is inserted through the mouth or nose into the trachea to provide a patent airway for clients who cannot maintain an adequate airway on their own. The scenario does not indicate infection, post operative bleeding, or a plugged tracheostomy tube.

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? Epistaxis, twice last week Laryngitis following a cold Hoarseness for 2 weeks Aphonia following a football game

Hoarseness for 2 weeks Explanation: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity.

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? Vocal cord stripping Cordectomy Total laryngectomy Partial laryngectomy

Partial laryngectomy Explanation: 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 has pharyngitis and will be providing self care at home. It is most important for the nurse to Properly dispose of used tissues Seek medical help if he experiences inability to swallow Stay in bed when experiencing a fever Place an ice collar on the throat to relieve soreness

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.

A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client: Sleep with the head of bed elevated. Caffeinated beverages are allowed. Do not perform saline irrigations to the nares. You may drink 1 glass of alcohol daily.

Sleep with the head of bed elevated. Explanation: General nursing interventions for chronic rhinosinusitis include teaching the client how to provide self-care. These measures include elevating the head of the bed to promote sinus drainage. Caffeinated beverages and alcohol may cause dehydration. Saline irrigations are used to eliminate drainage from the sinuses.

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 Makes a fist with one hand with the thumb outside the fist Stands behind the worker, who has hands across the neck Exerts pressure against the worker's abdomen Places both arms around the worker's waist

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.

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? Assess capillary refill. Auscultate lung sounds. Monitor heart rhythm. Obtain vital signs.

auscultate lung sounds. Explanation: Major goals of intubation are to improve respirations and maintain a patent airway for gas exchange. Regular auscultation of the lung fields is essential in confirming that air is reaching the lung fields for gas exchange. All other options are important to provide assessment data.

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 An antihistamine such as Benadryl An antibiotic such as amoxicillin An ointment such as bacitracin

An antiviral agent such as acyclovir Explanation: 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.

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? Take aspirin for nasal discomfort. Administer normal saline nasal drops as ordered. Decrease the amount of daily fluids. Avoid sports activities for 6 weeks.

Avoid sports activities for 6 weeks. Explanation: The nurse instructs the client to avoid sports activities for 6 weeks. There is no indication for the client to refrain from taking oral fluids. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. The client should take analgesic agents, such as acetaminophen or NSAIDs (i.e., ibuprofen or naproxen), to decrease nasal discomfort, not aspirin. The client does not need to use nasal drops when nasal packing is in place.

Which assessment finding puts a client at increased risk for epistaxis? Use of a humidifier at night History of nasal surgery Hypotension Cocaine use

Cocaine use Explanation: Using nasally inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased vascularity of the nasal passages. A dry environment (not a humidified one) increases the risk of epistaxis. Hypertension, not hypotension, increases the risk of epistaxis. A history of nasal surgery doesn't increase the risk of epistaxis.

Which of the following is the most effective treatment for obstructive sleep apnea (OSA)? Bilevel positive airway pressure (BiPAP) Oxygen by nasal cannula Mechanical ventilation Continuous positive airway pressure (CPAP)

Continuous positive airway pressure (CPAP) Explanation: CPAP is the most effective treatment for OSA because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient must be breathing independently. BiPAP ventilation offers independent control of inspiratory and expiratory pressure while providing pressure support ventilation. Mechanical ventilation is not the most effective treatment for OSA. Administration of low-flow nasal oxygen at night can help relieve hypoxemia in some patients but has little effect on the frequency or severity of apnea.

The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid wearing a plastic bib while showering. coughing. swimming. wearing a scarf over the stoma.

swimming. Explanation: Swimming is not recommended because a client with a laryngectomy can drown without submerging his or her face. Special precautions are needed in the shower to prevent water from entering the stoma. Wearing a loose-fitting plastic bib over the tracheostomy or simply holding a hand over the opening is effective. 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 surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: The voice was spared and a tracheostomy would be in place until the airway was established. A portion of the vocal cord was removed. One vocal cord was removed along with a portion of the larynx. A permanent tracheal stoma would be necessary.

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.

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

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 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 eat a lot of red meat?" "Have you strained your voice recently?" "Do you smoke cigarettes, cigars, or a pipe?" "Do you eat spicy foods?"

"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 scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube? "The ET tube will remain in place for at least a day postsurgery." "The ET tube will be inserted through an opening in your trachea." "The ET tube will be connected to a negative-pressure ventilator." "The ET tube will maintain your airway while you're under anesthesia."

"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 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. Cervical lymph adenopathy Hoarseness of more than 2 week's duration Dysphasia Persistent ulceration

Hoarseness of more than 2 week's duration Explanation: 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.

Select the nursing diagnosis that would warrant immediate health care provider notification. Acute pain related to upper airway irritation secondary to an infection Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation Deficient fluid volume related to decreased fluid intake and increased fluid loss secondary to diaphoresis associated with a fever Deficient knowledge regarding prevention of upper airway infections, treatment regimens, the surgical procedure, or postoperative care

Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation Explanation: Ineffective airway clearance can lead to respiratory depression, which necessitates immediate intervention.

A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by Applying pressure to the nose for 1 to 2 minutes Telling the client to sit upright with the head tilted forward Pinching the upper and hard portion of the nose Instructing the client to tilt the head back with ice applied to the nose

Telling the client to sit upright with the head tilted forward Explanation: Hemorrhage or massive bleeding from the nose is called epistaxis. Initial interventions include having the client sit upright with the head tilted forward to prevent swallowing and aspiration of blood. Tilting the head back will encourage the client to swallow and possibly aspirate blood. Pressure is applied to the soft outer portion of the nose against the midline septum, not the upper and hard portion of the nose. Pressure is also applied continuously for 5 to 10 minutes.

Stiffness of the neck or inability to bend the neck is referred to as nuchal rigidity. xerostomia. aphonia. dysphagia.

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.