Prep U Chapter 18 med surg

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: sit upright, leaning slightly forward. blow his nose and then put lateral pressure on his nose. lie supine with his neck extended. hold his nose while bending forward at the waist.

A 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. wearing a scarf over the stoma. wearing a plastic bib while showering. coughing.

A 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 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. Sleep on the back. Take a hypnotic medication at hours of sleep. Use nasal oxygen at night.

A The client's symptoms are consistent with obstructive sleep apnea. Initial treatment includes avoidance of alcohol and hypnotic medications. Clients are told to not sleep on their backs. Administration of nasal oxygen may help with hypoxemia but has little effect on the frequency of apnea.

A patient comes to the clinic complaining of a possible upper respiratory infection. What should the nurse inspect that would indicate that an upper respiratory infection may be present? The nasal mucosa The frontal sinuses The buccal mucosa The tracheal mucosa

A The nurse inspects the nasal mucosa for abnormal findings such as increased redness, swelling, exudate, and nasal polyps, which may develop in chronic rhinitis. The mucosa of the nasal turbinates may also be swollen (boggy) and pale bluish-gray. The nurse palpates the frontal and maxillary sinuses for tenderness, which suggests inflammation, and then inspects the throat by having the patient open the mouth wide and take a deep breath.

A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to Blow the nose before applying medication into the nares. Wait 10 seconds before administering the second spray. Tilt the head back when activating the spray of the medication. Clean the medication container once each day.

A The nurse instructs the client to blow the nose before administering the nasal medication. The client should keep the head upright, not tilted back. The client should wait at least 1 minute before administering the second spray and clean the container after each use.

The nurse knows that there are three types of chronic pharyngitis. Which of the following is characterized by numerous swollen lymph follicles on the pharyngeal wall? Atrophic Chronic granular Aphonia Hypertrophic

B Chronic granular pharyngitis is characterized by numerous swollen lymph follicles on the pharyngeal wall. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane.

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 increased tissue perfusion. The client will have decreased edema. The client will have decreased pain. The client will remain alert and oriented.

B Elevating the head of the bed 45 degrees when the client is fully awake decreases surgical edema and increases lung expansion. At this point in the recovery, elevating the head of the bed will not decrease the surgical pain as pain medication will be needed. Elevating the head of the bed will not affect mentation nor increase the blood supply.

The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care? Restrict fluid intake. Apply an ice pack. Apply pressure to the convex of the nose. Position the patient in the side-lying position.

B Following a nasal fracture, the nurse applies ice and encourages the client to keep the head elevated. The nurse instructs the client to apply ice packs to the nose to decrease swelling. The packing inserted to stop the bleeding may be uncomfortable and unpleasant, and obstruction of the nasal passages by the packing forces the client to breathe through the mouth. This, in turn, causes the oral mucous membranes to become dry. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. Applying direct pressure is not indicated in this situation.

A client seeks medical attention for a 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? Deviated trachea Sore throat Nausea Facial pain

B Hoarseness of more than 2 weeks' duration is a common symptom in the client with cancer of the larynx because the tumor impedes the action of the vocal cords during speech. Nausea is not a symptom of laryngeal cancer. Pain radiating to the ear and not to the face may occur if metastasis has occurred. A lump may be felt in the neck but the trachea is not affected.

The nurse is caring for a client receiving radiation therapy for laryngeal cancer. Which is a late complication of radiation therapy? Dysphasia Laryngeal necrosis Pain Xerostomia

B Late complications of radiation therapy include laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy.

Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy? deficient knowledge impaired verbal communication risk for chronic low self-esteem risk for infection

B 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.

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

B 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 client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for Hypertension Nuchal rigidity Nausea Mild headache

B 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.

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? Increased blood pressure Rapid, deep respirations Decreased pulse rate Warm, moist skin

B 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.

When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided? Coughing Swimming Wearing a scarf over the stoma Hand-held showers

B 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.

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

B 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.

The nurse is mentoring a new graduate nurse and the two are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. Which complication(s) would the nurse identify for the new nurse? Select all that apply. tracheal stenosis infection absence of secretions injury to the laryngeal nerve aspiration

B, D, E The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall. Tracheal stenosis may develop after the tube is removed.

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer? weight loss headaches in the morning a feeling of swelling at the back of the throat discomfort when drinking cold liquids

C After an initial hoarseness lasting longer than a month, clients with laryngeal cancer will feel a sensation of swelling or a lump in the throat or in the neck. Weight loss often occurs later in the progression of laryngeal cancer due to reduced calorie intake as a result of impaired swallowing and pain. Clients with laryngeal cancer may report burning in the throat when swallowing hot or citrus liquids. Clients with obstructive sleep apnea may experience a morning headache.

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? "Oral intake of fluids should be limited for 1 week only." "Clean the tracheostomy tube with alcohol and water." "Family members should continue to talk to the client." "Limit the amount of protein in the diet." SUBMIT ANSWER

C 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.

The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? Incrusted mucous membranes Erosion of the trachea Noisy breathing Hardened secretions

C 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.

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of 3 to 6 months. 1 to 3 months. 2 to 12 days. 20 to 30 days.

C HSV-1 is transmitted primarily by direct contact with infected secretions. The time periods of 20 to 30 days, 1 to 3 months, and 3 to 6 months exceed the incubation period.

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? Provide emphatic oral instructions for the client. Provide the client with oral penicillin that will last for 5 days. Administer one intramuscular injection of penicillin. Ask an accompanying homeless friend to monitor the client's follow-up.

C 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.

The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include? "A speech therapist will evaluate you and recommend a system of communication after surgery." "You can use writing or a communication board to communicate." "After surgery you will have a sore throat, but you will be able to speak."

C 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.

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? Supraglottic laryngectomy Total laryngectomy Partial laryngectomy Hemilaryngectomy

C 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.

Another term for clergyman's sore throat is aphonia. hypertrophic pharyngitis. chronic granular pharyngitis. atrophic pharyngitis.

C In chronic granular pharyngitis, also referred to as clergyman's sore throat, the pharynx is characterized by numerous swollen lymph follicles. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane.

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

C Ineffective airway clearance can lead to respiratory depression, which necessitates immediate intervention.

As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that: inhaling polluted air isn't a risk factor for laryngeal cancer. laryngeal cancer occurs primarily in women. laryngeal cancer is one of the most preventable types of cancer. adenocarcinoma accounts for most cases of laryngeal cancer.

C Laryngeal cancer is one of the most preventable types of cancer; it can be prevented by abstaining from excessive drinking and smoking. Inhaling noxious fumes, such as in polluted air, is a risk factor for laryngeal cancer. Roughly 80% of laryngeal cancer cases occur in men. Squamous cell carcinoma accounts for most cases of laryngeal cancer.

Most cases of acute pharyngitis are caused by which of the following? Fungal infection Bacterial infection Viral infection Systemic infection

C Most cases of acute pharyngitis are caused by viral infection. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus.

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? Magnetic resonance imaging (MRI) Nasal culture Transillumination of the sinus CBC with differential

C 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 at an employee wellness clinic is meeting with a client who reports voice hoarseness for more than 2 weeks. To determine if the client may have symptoms of early laryngeal cancer, the next question the nurse should ask is, "Do you have difficulty swallowing foods" a foul odor to your breath" trouble with your breathing" a persistent cough or sore throat"

D Hoarseness longer than 2 weeks with a persistent cough or sore throat are early symptoms of laryngeal cancer. Later symptoms of laryngeal cancer include dysphagia, dyspnea, and foul breath.

A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to Apply an ice pack to the nose. Reassure the client that the nose is not fractured. Administer prescribed oral ibuprofen (Motrin). Check the clear fluid for glucose.

D The client's signs and symptoms are consistent with a fracture of the nose. Clear fluid draining from either nostril suggests leakage of cerebrospinal fluid. This can be checked by assessing for glucose, which is in cerebrospinal fluid. This finding is important to identify, because infection can be transmitted through the opening in the cribriform plate. Other options, such as applying an ice pack to the nose and administering ibuprofen, are appropriate interventions but not most important for this client. Reassuring the client that the nose is not fractured is premature until all assessments are completed.

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

D 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.

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? Pseudomonas aeruginosa Gram-negative Klebsiella Staphylococcus aureus Group A, beta-hemolytic streptococci

D Viral infection causes most cases of acute pharyngitis. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus. Bacterial infection accounts for the remainder of cases. Ten percent of adults with pharyngitis have group A beta-hemolytic streptococcus (GABHS), which is commonly referred to as group A streptococcus (GAS) or streptococcal pharyngitis.

A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect? Chronic tonsillitis Laryngeal polyps Laryngeal cancer Chronic pharyngitis

C Persistent hoarseness (longer than 2 weeks) is usually the earliest symptom.

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events? Increased smooth muscle contractility Pulmonary hypotension Systemic hypotension Hypercapnia

D Repetitive apneic events result in hypoxia and hypercapnia, which triggers a sympathetic response (increased heart rate and decreased tone and contractility of smooth muscle).

Which diagnostic test is used to confirm the diagnosis of maxillary and frontal sinusitis? Sinus x-rays MRI CT scan Sinus aspirates

D Sinus aspirates may be obtained to confirm the diagnosis of maxillary and frontal sinusitis and identify the pathogen. Sinus x-rays and CT scans may be obtained for patients with frontal headaches, in refractory cases, and if complications are suspected.

A client with acute viral rhinosinusitis is being seen in a clinic. The nurse is providing discharge instructions and includes the following information: Avoid air travel. Dehumidify the air in the home. Make sure to follow antibiotic therapy. Severe pain when palpating the sinuses is normal.

A Information that the nurse should include for a client with acute viral rhinosinusitis is to avoid air travel. Other nursing interventions include referring the client to a physician if severe pain occurs when palpating the sinuses and humidifying the air in the home to promote drainage. Antibiotic therapy is not indicated for a viral infection.

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 Cold compresses to the sinus cavities Administration of oral antibiotics Use of a dehumidifier

A 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 client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about? Amoxicillin-clavulanic acid Clarithromycin Cefuroxime Cephalexin

A Treatment of acute rhinosinusitis depends on the cause; a 5- to 7-day course of antibiotics is prescribed for bacterial cases. Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid ( Augmentin) is the antibiotic of choice. Other antibiotics prescribed previously to treat ABRS, including cephalosporins such as cephalexin (Keflex), cefuroxime (Ceftin), cefaclor (Ceclor), and cefixime (Suprax), trimethoprim-sulfamethoxazole (Bactrim, Septra), and macrolides such as clarithromycin (Biaxin) and azithromycin (Zithromax), are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.

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 permanent tracheal stoma would be necessary. One vocal cord was removed along with a portion of the larynx. A portion of the vocal cord was removed.

B 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.

A client is postoperative immediately following a total laryngectomy. The client's respirations are 32 breaths/minute, shallow, and noisy. The tracheostomy pad is moist with mucus. Pulse oximetry is 88%. The client's eyes are wide open, and the client appears apprehensive. What is a priority nursing concern? Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Anxiety

B All may be appropriate nursing diagnoses for this client. The nurse would follow Maslow's hierarchy of needs and ABCs (airway, breathing, circulation) to determine the highest priority. Ineffective airway clearance is the nursing diagnosis of highest priority.

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 Acute pain related to upper airway irritation Ineffective airway clearance related to excess mucus production Deficient fluid volume related to increased fluid needs Deficient knowledge related to prevention of upper respiratory infections

B 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.

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

B 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.

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 sleep on my side all night long." "I need to keep my inhaler at the bedside." "I should become involved in a weight loss program." "I should eat a high-protein diet."

C 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.

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? Pseudomonas aeruginosa Staphylococcus aureus Group A, beta-hemolytic streptococcus Gram-negative Klebsiella

C The adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. Infection of the adenoids frequently accompanies acute tonsillitis. Frequently occurring bacterial pathogens include group A, beta-hemolytic streptococcus, the most common organism.

The nurse in the ICU is caring for a client with a nasotracheal tube. Because of the tube placement, the nurse understands that the client is at risk for developing subperiosteal abscess. severe epistaxis. orbital cellulitis. sinus infection.

D Clients with nasotracheal and nasogastric tubes in place are at risk for developing sinus infections. Thus, accurate assessment of clients with these tubes is critical. Removal of the nasotracheal or nasogastric tube as soon as the client's condition permits allows the sinuses to drain, possibly avoiding septic complications. Severe epistaxis is not a complication of nasotracheal placement. Subperiosteal abscess and orbital cellulitis are complications of chronic rhinosinusitis.

The nurse is caring for a client diagnosed with rhinosinusitis. The physician has ordered the client to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the client that a common side effect of this medication is Headache Arthralgia Watery eyes Epistaxis

D Common side effects of budesonide (Rhinocort) include epistaxis, pharyngitis, cough, nasal irritation, and bronchospasm.

The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation? Harsh cough Bilateral breath sounds present Copious mucous secretions Sudden restlessness

D 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. Bilateral breath sounds are an expected finding; the absence of bilateral breath sounds should be reported to the provider immediately.

A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis? Provide a nasal splint. Place the client in a semi-Fowler's position. Apply a moustache dressing. Apply direct continuous pressure.

D 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 presents to the ED with a 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 for endotracheal intubation with mechanical ventilation. Apply 100% oxygen via a face mask. Prepare for immediate tracheostomy. Prepare to administer subcutaneous epinephrine and corticosteroids.

D The use of accessory muscles to maximize airflow is often manifested by retractions in the neck during inspiration and is an ominous sign of impending respiratory distress. The client's obstruction is caused by edema resulting from an allergic reaction, and treatment should include immediate administration of subcutaneous epinephrine and a corticosteroid. The other interventions may be indicated for a client with a laryngeal obstruction; however, in this instance the most appropriate intervention to treat the client's laryngeal edema is the administration of the medications.

The nurse is performing preoperative teaching with a client who has been diagnosed with cancer of the larynx. After completing client teaching, what would be most important for the nurse to do? Provide the client with audiovisual materials about the surgery. Give the client his or her cell phone number. Refer the client to a social worker or psychologist. Reassure the client and family that everything will be alright.

A Informational materials (written and audiovisual) about the surgery are given to the client and family for review and reinforcement. The nurse never gives personal contact information to the client. Nothing in the scenario indicates that a referral to a social worker or psychologist is necessary. False reassurance must always be avoided.

An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by periods of breathing cessation for: 10 seconds with 5 episodes/hour. 4 seconds with 2 episodes/hour. 6 seconds with 3 episodes/hour. 8 seconds with 4 episodes/hour.

A OSA is characterized by frequent and loud snoring, with breathing cessation for 10 seconds or longer, for at least five episodes per hour, followed by abrupt awakening with a loud snort as the blood oxygen level drops. Symptoms typically progress with weight gain, aging, and during the transition to menopause for women.

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. Encourage sweet foods. Offer plenty of thin liquids. Liberally season foods.

A 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.

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? "I have environmental allergies." "I was chewing ice chips all day long." "I used my voice in excess over the weekend." "I smoke a pack of cigarettes a day."

B 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 remain in place for at least a day postsurgery." "The ET tube will maintain your airway while you're under anesthesia." "The ET tube will be connected to a negative-pressure ventilator." "The ET tube will be inserted through an opening in your trachea."

B 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.

The nurse is teaching a group of adults at a community center about common colds. Which treatment option would the nurse include in this presentation? antibiotics antihistamines bronchodilators opioids

B Antihistamines are the first group of medications recommended for treating sneezing, pruritus, rhinorrhea, and nasal congestion associated with the common cold. Common colds are caused by viruses, so antibiotics are not effective. Over-the-counter analgesics may be used, but not opioids; opioids are prescribed for severe pain. Bronchodilators are used to treat long-term conditions causing a narrowing or inflammation of the airway.

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? No fluid is normally present 20 mL or less 20-40 mL More than 40 mL

B The pleural space, located between the visceral and parietal pleura, normally contains 20 mL of fluid or less. The fluid helps lubricate the visceral and parietal pleura.

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

B 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.

A client has had laryngeal surgery. What are the expected client outcomes? Select all that apply. The client's breathing patterns improve. The client's suture line remains intact. The client can swallow without difficulty. The client maintains an adequate caloric intake. The client can manage his or her own secretions.

B, D, E The caloric and fluid intake of a client undergoing laryngeal surgery should be adequate. The suture line must be intact. The client needs to manage own secretions. Swallowing abilities are evaluated in clients undergoing tonsillectomy and adenoidectomy. Improved breathing patterns are evaluated in the case of clients with trauma in the upper airway.

A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client? "You are allowed to have hot tea or coffee." "Decrease oral intake if increased swallowing occurs." "Gargle with a warm salt solution." "You may have a sore throat for 1 week."

C 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.

An adolescent client sustains a fractured nose during a high school basketball game. Which action will the school nurse take first to help this client? Pack the nose with rolled gauze pads. Explain how the nose will need to be reset. Apply ice with the client in a seated position. Call for transportation to the nearest emergency room.

C Nasal fracture is the most common facial fracture and the most common fracture in the body. The signs and symptoms of a nasal fracture are pain, bleeding from the nose externally and internally into the pharynx, swelling of the soft tissues adjacent to the nose, periorbital ecchymosis, nasal obstruction, and deformity. The client's nose may have an asymmetric appearance that may not be obvious until the edema subsides. Immediately after the fracture, ice is applied and the client is instructed to keep the head elevated. The client should then be taken for emergency care when rolled gauze pads may be used to stop bleeding. Resetting of the nose may not occur for 3 to 7 days after the injury because of the edema.

patient with an advanced laryngeal tumor is to have radiation therapy. The patient tells the nurse, "If I am going to have radiation, I won't need surgery." What is the best response by the nurse? "All patients have to have radiation before they have surgery. It is protocol." "That is correct. The radiation will eradicate the tumor and you won't have to have further treatment." "Radiation is used to shrink the tumor size and is an adjunct to surgery." "You really don't have to have radiation but you won't have to have such invasive surgery if you have the radiation first."

C Radiation therapy may also be used preoperatively to reduce the tumor size. Radiation therapy is combined with surgery in advanced laryngeal cancer as adjunctive therapy to surgery or chemotherapy and as a palliative measure.

Which is the priority nursing diagnosis for a client undergoing a laryngectomy? Impaired verbal communication Imbalanced nutrition: Less than body requirements Ineffective airway clearance Anxiety and depression

C 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.

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? Infection Postoperative bleeding Edema of the upper airway Plugged tracheostomy tube

C 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.

Wound drains, inserted during the laryngectomy, stay in place until what criteria are met? The surgical site is dry with encrustations. The stoma is healed, about 6 weeks after surgery. The patient is able to assist with his own suctioning. Drainage is <30 mL/day for 2 consecutive days.

D Drains are removed when secretions are minimal, which usually is less than 30 mL for 48 straight hours.

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 polyps Cancer of the tonsils Cancer of the pharynx Laryngeal cancer

D 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.