Chapter 22: Management of Patients with Upper Respiratory Tract Disorders
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 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 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 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 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." Explanation: A sudden and complete loss of voice and cough are symptoms of laryngitis. The nurse instructs the client to avoid irritants, such as smoking. Voice rest is indicated. Whispering places stress on the larynx. Inhaling cool steam or aerosal aids in the treatment. Dry air may make the symptoms worse. A "tickle" in the throat that many clients report is actually worsened with cold liquids.
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 Explanation: Potential complications of acute bacterial rhinosinusitis are nuchal rigidity and severe headache. Hypertension may be a result of over-the-counter decongestant medications. Nausea may be a result of nasal corticosteroids.
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 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.
Bleeding from the drains at the surgical site or with tracheal suctioning may signal the occurrence of hemorrhage. Which of the following is a clinical manifestations associated with hemorrhage?
Rapid, deep respirations Explanation: The nurse monitors the vital signs for increased pulse rate, decreased blood pressure, rapid deep respirations, restlessness, and delayed capillary refill. Cold, clammy skin may indicate active bleeding.
A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client:
Sleep with the head of bed elevated.
Most cases of acute pharyngitis are caused by which of the following?
Viral infection Explanation: Most cases of acute pharyngitis are caused by viral infection. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus.
Wound drains, inserted during the laryngectomy, stay in place until what criteria are met?
Drainage is <30 mL/day for 2 consecutive days. Explanation: Drains are removed when secretions are minimal, which usually is less than 30 mL for 48 straight hours.
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 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 herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of
2 to 12 days Explanation: HSV-1 is transmitted primarily by direct contact with infected secretions. The incubation period is about 2 to 12 days. The time periods of 20 to 30 days, 1 to 3 months, and 3 to 6 months exceed the incubation period.
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. 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.
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 Explanation: With severe respiratory distress in a status post adenoidectomy client, the nurse would suspect an airway issue related to edema of the upper airway. The scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy tube.
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?"
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." Explanation: Commonly, family members are reluctant to talk to the client who has had a total laryngectomy and can no longer speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing.
A client is being discharged from an outpatient surgery center following a tonsillectomy. The nurse gives the following instructions:
"Gargle with a warm salt solution." Explanation: 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 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." Explanation: 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.
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." Explanation: Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes.
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 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 caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?
Administer an over-the-counter decongestant. Explanation: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opens the nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best.
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. Explanation: 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.
You are caring for a client who has just been told they have advanced laryngeal cancer and will have to have a total laryngectomy. You are doing preoperative teaching with this client. What do you know is a subject you should cover?
Alternative methods of communication Explanation: Discuss alternative methods of communication and identify which method the client prefers. Visiting hours, pain and post operative nutrition are not generally covered at this point in preoperative teaching.
Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)?
Amoxicillin Explanation: Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid is the antibiotic of choice. For clients who are allergic to penicillin, doxycycline or respiratory quinolones, such as levofloxacin or moxifloxacin, can be used. Other antibiotics previously prescribed to treat ABRS, including cephalosporins such as cephalexin and cefuroxime, are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.
The nurse is caring for a client experiencing laryngeal trauma. Upon assessment, swelling and bruising is noted to the neck. Which breath sound is anticipated?
Audible stridor without using a stethoscope Explanation: The nurse anticipates hearing audible stridor without needing a stethoscope due to the neck swelling narrowing the airway. Rhonchi in the bronchial region is heard lower in the airways and crackles are heard in the bases of the lungs. Diminished breath sounds that occur throughout are indicative of airway obstruction and not indicative of laryngeal swelling.
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 comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis?
Apply direct continuous pressure. Explanation: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.
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. Explanation: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.
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 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. 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.
Which assessment finding puts a client at increased risk for epistaxis?
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.
You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis?
Encourage deep breathing every 2 hours.
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
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.
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.
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 Explanation: All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis.
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. Explanation: Postoperatively, the client may not be permitted to eat or drink for at least 7 days. Alternative sources of nutrition and hydration include IV fluids, enteral feedings through a nasogastric or gastrostomy tube, and parenteral nutrition. Once the client is permitted to resume oral feedings, thick liquids are offered; sweet foods are avoided because they cause increased salivation and decrease the client's appetite. The client's taste sensations are altered for a while after surgery because inhaled air passes directly into the trachea, bypassing the nose and the olfactory end organs. In time, however, the client usually accommodates to this change and olfactory sensation adapts; thus, seasoning is based on personal preferences.
A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?
Laryngeal cancer
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 Explanation: Later, the client notes a sensation of swelling or a lump in the throat, followed by dysphagia and pain when talking. Hoarseness is not indicative of pharyngeal cancer; laryngeal polyps; or cancer of the tonsils.
The nurse is caring for a client receiving radiation therapy for laryngeal cancer. Which is a late complication of radiation therapy?
Laryngeal necrosis Explanation: Late complications of radiation therapy include laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy.
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
Noisy breathing Explanation: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following a tracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.
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 assesses a patient for possible acute pharyngitis. Which of the following clinical manifestations are consistent with this diagnosis? Select all that apply.
Red pharyngeal membranes Swollen lymphoid follicles White-purple exudates on the back of the throat A temperature >100.4°F Explanation: Acute pharyngitis is not characterized by a cough. All the other symptoms are present.
A client is experiencing acute viral rhinosinusitis. The nurse is providing instructions about self-care activities and includes information about
Saline lavages to the nares Explanation: Saline lavages are used for acute rhinosinusitis and relieve symptoms, reduce inflammation, clear nasal passages of stagnant mucus, and reduce the development of opportunistic infections. Other methods that promote drainage of the sinuses are humidifying the air, not dehumidifying it, and warm compresses, not cold compresses, to the sinus cavities. Because this infection is viral, antibiotics are not indicated.
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.
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.
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 Explanation: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube. A harsh cough and rhonchi in the lung fields is common with the presence of mucous secretions.
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.
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 Explanation: Transillumination and x-rays of the sinuses may show a change in the shape of or confirms that there is fluid in the sinus cavity. CBC with differential can note an elevated white blood cell count but not confirm fluid in the sinus cavity. A nasal culture can note bacteria in the nares. An MRI is an expensive procedure which is not typically prescribed for a potential infection and not specifically ordered to identify fluid in the sinus cavity.
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.
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." Explanation: 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.
Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?
impaired verbal communication Explanation: 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.
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward. Explanation: 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.
The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid
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.
