MED SURG CHAP 14 Care of Patients with Disorders of the Upper Respiratory System

A 55-year-old man with a new tracheostomy is unable to cough. Breath sounds are diminished. Pulse oximetry is 88% on 100% humidified air. What is the priority nursing action? 1.Provide positive ventilation. 2.Suction respiratory secretions. 3.Administer pain medications. 4.Humidify inhaled air.

. Correct Answer: 2 Rationale: The patient is most likely to have excess secretions that are blocking the airway. Positive ventilation is inappropriate when the airway is mechanically obstructed. Pain is not the current priority, and medication could dampen respiratory efforts. Humidifier is already in place

A 45-year-old man who is eating steak suddenly rises from his seat. His hands are grasping his throat. What immediate action should be performed? 1. Perform finger sweeps when food bolus is seen. 2. Wrap the arms around the victim from behind. 3. Position the open hand just above the nipple line. 4. Deliver three downward squeeze thrusts.

2. Correct Answer: 2 Rationale: Position yourself behind the man and wrap your arms around him to perform abdominal thrusts (Heimlich maneuver). Finger sweeps, positioning the hand above the nipple line, and downward squeeze thrusts are not recommended techniques.

A patient arrives in the emergency room holding a towel up to his face, which is saturated with bright red drainage. He tells you he was accidentally "hit with a piece of wood" approximately 30 minutes ago. What is the immediate nursing priority? Assess the patient's airway patency.

Airway patency is always the priority. The patient is able to speak and be understood, so he has at least a partial airway. Gloves can be donned at the same time airway patency is being assessed. Removing the towel at this time may remove the pressure that is stopping a larger hemorrhage. Reinforce the area with gauze sponges and notify the physician of the situation. The specific injury has not been determined yet; applying ice and/or pressure may do more damage to the injured area.

The nurse is caring for a patient with epistaxis who is to be taken for x-rays of the skull and face. What nursing interventions will be necessary? (Select all that apply.) Compressing the bleeding nostril against the septum and applying ice Monitoring airway patency Keeping the patient's head elevated at 30 to 45 degrees

Airway patency is always the priority; compression of the nostril and application of ice to the area are standard actions to control epistaxis. Elevating the patients head 30 to 45 degrees helps to ensure that drainage from the epistaxis will flow downward into the gastrointestinal (GI) tract, not the respiratory tract.

The nurse is caring for a patient who has had a tonsillectomy. Which observation may indicate bleeding at the operative site? The patient swallows frequently.

As blood runs down the throat, the patient will frequently swallow. Throat pain is expected and does not necessarily indicate bleeding. Refusing to lie on his side or being frightened when moving his neck does not indicate bleeding.

The spouse of a patient with a tracheostomy asks, "Why did the physician order a fenestrated tracheostomy tube?" What is the best response? 1."It prepares the patient for long-term tracheostomy." 2."It allows gradual weaning before closure of the tracheostomy." 3."It prevents aspiration of mucus and fluids." 4."It reduces the risk for tracheal wall necrosis."

Correct Answer: 2 Rationale: Fenestrated tubes have a small opening in the outer cannula that allows some air to escape through the larynx. This helps prepare the patient for the time when the tracheostomy tube will be removed and breathing occurs normally again. Tubes made of metal alloys are used chiefly for patients who need a permanent tracheostomy. Cuffed tracheostomy tube may offer some protection against aspiration of mucus and fluids. Foam-cuffed tracheostomy tubes are disposable and cause minimal tissue necrosis.

A patient is newly diagnosed with a squamous cell carcinoma of the larynx. What is an early sign and symptom for this diagnosis? 1. Crepitation 2. Hoarseness 3. Frothy sputum 4. Drooling

Correct Answer: 2 Rationale: Hoarseness is an early symptom in cancer of the larynx. Crepitation occurs when fractured bone surfaces rub together. Frothy sputum is most frequently associated with pulmonary emboli. Drooling may occur because of neurologic disorders (e.g., stroke) or in airway obstruction (e.g., epiglottitis, or large tumor).

The student nurse demonstrates endotracheal suctioning. Which action indicates a need for further instructions? 1.Donning sterile gloves before suctioning 2.Lubricating the suction catheter with lubricating jelly 3.Assessing the need for suctioning 4.Checking the suction hookup

Correct Answer: 2 Rationale: The tube should not be lubricated with jelly. A small amount of sterile normal saline may be used to test the suction and moisten the tube. Suctioning is a sterile procedure. Need for suctioning should always be assessed prior to performing. Checking equipment is standard procedure.

On initial assessment, the patient who just had tonsillectomy and adenoidectomy is restless and swallows frequently. What is the most likely explanation? 1.Excessive thirst 2.Swelling in the neck 3.Bleeding 4.Sore throat

Correct Answer: 3 Rationale: The chief concern is hemorrhage. The patient is restless and demonstrates frequent swallowing, which suggest excessive bleeding. Swelling and excessive thirst could be secondary to hemorrhage, which should be ruled out. If swelling is noted, respiratory effort should be assessed. Sore throat is expected.

The nurse is caring for a patient who is postoperative for tonsillectomy. Within the first 24 hours, which food item would be the most appropriate to offer the patient? 1.Orange juice 2.Warm tea 3.Soda crackers 4.Popsicles

Correct Answer: 4 Rationale: Cool fluids, ice chips, popsicles, or non-red-colored gelatin can be offered to the patient. Acidic, warm, or solid foods need to be held until the patient has progressed toward a normal diet.

When caring for the patient who had a rhinoplasty, the nurse should perform which intervention(s) in the immediate postoperative period? (Select all that apply.) 1.Observe for frequent swallowing. 2.Monitor amount of drainage on dressing. 3.Position patient flat on the back. 4.Apply warm compresses. 5.Provide humidified oxygen.

Correct Answers: 1, 2, 5 Rationale: Observing for frequent swallowing and monitoring the amount of drainage on the dressing are appropriate because of the danger of hemorrhage. A humidifier is used to decrease mucosal drying. The patient should be in a semi-Fowler's position. Cool compresses are utilized to decrease nose and facial swelling.

While deciding whether to sign the surgical consent for tracheostomy, the patient's spouse asks, "What is the purpose of this procedure?" Which response(s) demonstrate(s) nursing knowledge regarding the procedure? (Select all that apply.) 1."The procedure facilitates suctioning of respiratory secretions." 2."The procedure prevents recurrence of respiratory arrest." 3."The procedure prevents hospital-acquired pneumonia." 4."The procedure bypasses an obstructed upper airway." 5."The procedure is a temporary airway for face and neck injuries."

Correct Answers: 1, 4, 5 Rationale: Tracheostomy facilitates suctioning of respiratory secretions, bypasses an obstructed upper airway, and is a temporary airway for face and neck injuries. Tracheostomy does not prevent recurrence of respiratory arrest or hospital-acquired pneumonia.

The patient has sinusitis. Which nonpharmacologic intervention(s) would be appropriate? (Select all that apply.) 1. Apply ice packs over the sinus area. 2. Suggest inhalation of moist steam. 3. Increase fluid intake. 4. Decrease dairy product intake. 5. Rest, and reduce stress. 6. Use a sinus irrigation kit.

Correct Answers: 2, 3, 4, 5, 6 Rationale: Inhalation of moist steam, increased fluid intake, decreased dairy product intake, rest, and reduced stress and use of a sinus douche kit are all appropriate. Warm packs—not ice packs—can be applied over the sinus area.

A patient with a sore throat is to have a throat culture to establish whether the infection is being caused by Streptococcus pyogenes. If it is a streptococcal infection and the patient is not treated, what may the patient be at risk for? Glomerulonephritis

Streptococcus pyogenes can invade the kidney or heart if the infection is left untreated, causing glomerulonephritis or rheumatic fever.

During the rehabilitation period, a patient who has had a laryngectomy seems very depressed and tells the LPN/LVN that he does not know how he will manage. Which action is likely to be most helpful? Arrange to have the patient meet someone who has had the surgery and is managing well.

Depression is not uncommon when the patient has undergone a drastic lifestyle change as a result of this type of surgery. Having the patient meet with another person with the same condition will be most helpful because this person will know what the patient is experiencing and can offer hope and suggestions for how to manage the condition.

A patient presents at the emergency room complaining of severe sore throat "that's so bad I can hardly swallow. It feels like there's a huge lump in my throat." She is diagnosed with severe pharyngitis. What should the nurse include in patient teaching regarding this condition? Increase her fluid intake to 2500 mL a day.

Increasing her fluid intake will thin any secretions that develop and keep her from becoming dehydrated. Decreased humidity will thicken secretions and create more difficulty swallowing. Because of the vitamin C content, fruit juices will help the immune system and ability to fight the infection. Hot baths or showers pose no problem for this patient.

A patient's nose begins to bleed. Which action should the LPN/LVN take? Have the patient apply direct pressure by pinching his nose for 10 to 15 minutes.

The patient should lean forward and apply pressure by pinching his nose for 10 to 15 minutes. Blowing the nose will increase bleeding, as will applying heat. Swallowing may lead to nausea and vomiting from blood entering the stomach.

A patient who has a severe upper respiratory infection is placed on antibiotics. Why is it important for the LPN/LVN to remind the patient to finish taking all of the antibiotic medication prescribed? Taking the entire antibiotic prevents the development of infections that are resistant to the antibiotic.

It is important to remind patients to take every dose of the prescription antibiotic in order to adequately kill all causative microorganisms. Disease-resistant strains of bacteria occur when only a portion of the prescribed dose of antibiotic is taken.

The nurse is performing an admission assessment on a patient who is scheduled for several diagnostic respiratory procedures. Which symptom reported by the patient would make the nurse suspect the patient may have laryngeal cancer? Persistent hoarseness Correct

Laryngitis lasting longer than 2 weeks is considered ominous and should be followed up with a physician. Anemia is an issue that usually results from the effects of chemotherapy on bone marrow. Difficulty swallowing may indicate a problem within the esophagus. A lump in the neck may be an enlarged lymph node.

Narcotic analgesics are often ordered for patients with respiratory disorders, even though a common side effect of these drugs is respiratory depression. Which rationale would explain narcotic use in these situations? Narcotics decrease oxygen demand.

Morphine, in particular, decreases anxiety, thereby reducing oxygen demands of the body.

The nurse assesses a patient and notices nasal flaring. What does the nurse suspect as the reason for this finding? Hypoxia

Nasal flaring is a sign of inadequate oxygen in body tissues. Nasal flaring is an early sign of respiratory compromise. Nasal flaring is not a sign of a specific disease process. Signs of low blood oxygen levels manifest more acutely than those of hypoxia and include cyanosis.

Common patient complaints associated with respiratory disorders include: dyspnea, fatigue, weakness. Correct

Shortness of breath or difficulty breathing can lead to fatigue and weakness because of the amount of energy necessary to breathe. Although many patients with respiratory disorders complain of coughing and dyspnea, pain is uncommon. Headache and palpitations are unusual for respiratory patients, unless they occur as adverse effects of medications used in treatment (notably aminophylline and theophylline). Confusion may result from severe hypoxia; however, pain is unusual and edema generally results from a cardiovascular, renal, or liver dysfunction.

A patient tells the nurse, "I went to the dentist a few days ago. I was sure I had a bad toothache; my upper teeth hurt so much. But the dentist told me my teeth were fine and that I should see my physician." What do these symptoms most likely indicate? Maxillary sinus infection

Sinusitis can cause pressure from mucus and purulent drainage buildup to affect nearby anatomical structures; in this patient's case, the maxilla. Significant pain and discomfort are often the result.

The LPN/LVN is to assist a patient with a partial laryngectomy with eating. The nurse should understand that it is best to begin by giving which of these types of food? Semisolid

Soft or semisolid foods will be the easiest consistency for the patient to eat initially. Liquids may lead to aspiration, fibrous foods will be difficult to swallow, and most sweet foods lack the nutrients necessary for the healing process.

The nurse is caring for a patient following a total laryngectomy. What interventions should the nurse anticipate will be needed? (Select all that apply.) Perform tracheostomy care. Maintain aspiration precautions. Develop an alternate communication method

The patient will first have a laryngectomy tube and then a standard tracheostomy because of postoperative edema that could cause airway obstruction. Aspiration will be a risk initially. Because laryngectomy patients lose the ability to speak, devising an alternative means of communication with the patients input is a priority.

The nurse is caring for a patient who has recently had a supraglottic laryngectomy. Which nursing diagnosis is most appropriate for this patient? Impaired verbal communication related to loss of larynx

The patient with a recent laryngectomy will not be able to speak. It will be important for the nurse to assist the patient in an alternative method of communication during the initial postoperative period and to find a new style of speech.

The nurse is caring for a patient who has had a stroke that has resulted in a weakened cough reflex. What is this patient most at risk for? Aspiration

The patient with a weakened cough reflex is most at risk for aspiration of food or fluids, which often leads to aspiration pneumonia.

For which of these reasons is it particularly important for elderly people to receive influenza immunizations? They are more susceptible to upper respiratory infections.

They tend not to seek medical assistance soon enough. The elderly tend to have a weaker immune system so it is important for them to receive an influenza immunization to help protect them from developing this infection, which can lead to secondary infections.

The nurse is planning the care for a patient who has had a laryngectomy. During the immediate postoperative period, how often will the nurse need to suction the tracheostomy of this patient? Every 4 hours and PRN Correct

This is the usual patient course for the first several days after surgery. It is imperative that the nurse assess the patient frequently, in case the secretions increase or become tenacious. Suctioning every 30 minutes is usually unnecessary, but patients should be assessed regularly for increased secretions. Every hour or 2 hours is acceptable, but every 4 hours and PRN is the better answer because it allows for individual patient needs.