management of patients with upper respiratory tract disorders (C18)

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."

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

Which assessment finding puts a client at increased risk for epistaxis?

Cocaine use

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 the room. What do you suspect?

Edema of the upper airway

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

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

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 providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid

Swimming

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 assessment finding puts a client at risk for epistaxis?

cocaine use

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

Which diagnostic test is used to confirm the diagnosis of maxillary and frontal sinusitis?

sinus aspirates

The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?

total laryngectomy

The herpes simplex virus type 1 which produces a cold sore has an incubation period of

2-12 days page 498

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

A permanent tracheal stoma would be necessary Page 516

The nurse 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 30mL for 2 consecutive days

Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)?

amoxicillin

A nurse is caring for a client who has just had a total laryngectomy. What is [art of the client's plan of care related to te surgery?

develop an alternative communication method

A client who has been diagnosed with an early glottis cancer would likely undergo which type of surgery?

laser microsurgery

A 73 year old client is admitted to the pulmonary 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

A first line antibiotic used to treat acute bacterial rhinosinusitis (ARBS) is

amoxicillin - clavulanic acid

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 pace. Which intervention should the nurse include in the client's care?

apply an ice pack

A client comes into the ED 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

Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?

continuous positive airway pressure (CPAP)

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 page 511

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

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

hoarseness

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 page 510

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

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

impaired verbal communication

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2. The client states this is the third episode this season. The highest priority nursing diagnosis is

ineffective airway clearance related to excess mucus production

Select the nursing diagnosis that would warrant immediate health care provider notification.

ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation

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

noise breathing page 505

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 layrngectomy

A client presents to the ED with suspected allergic reaction. The client is experiencing laryngeal edema, which is causing obstruction and is demonstrating retractions in the neck during inspiration. Which is the nurse's priority intervention?

prepare to administer subcutaneous epinephrine and corticosteroids

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

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 finding indicative of ____

purulent nasal drainage rhinosinusitis

A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive mucous production. The best short term goal is for the client to

report decreased congestion

A client seeks medical attention for hoarseness that has lasted for more than 2 weeks. Which additional finding indicates to the nurse that the client may need to be evaluated for cancer of the larynx?

sore throat

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

The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, "elevate the head of the bed 45 degrees." This assists in meeting which nursing goal?

the client will have decreased edema