Ch 22
A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in her teaching? a) "Cover the stoma whenever you shower or bathe." b) "Swimming is good exercise after this surgery." c) "Wear a tight cloth at the stoma to prevent anything from entering it." d) "Keep the humidity in your house low."
"Cover the stoma whenever you shower or bathe." The nurse should instruct the client to gently cover the stoma with a loose plastic bib, or even a hand, when showering or bathing to prevent water from entering the stoma. The client should cover the stoma with a loose-fitting, not tight, cloth to protect it. The client should keep his house humidified to prevent irritation of the stoma that can occur in low humidity. The client should avoid swimming, because it's possible for water to enter the stoma and then enter the client's lung, causing him to drown without submerging his face.
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says: a) "I should eat a high-protein diet." b) "I should sleep on my side all night long." c) "I should become involved in a weight loss program." d) "I need to keep my inhaler at the bedside."
"I should become involved in a weight loss program." 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 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? a) Provide emphatic oral instructions for the client. b) Ask an accompanying homeless friend to monitor the client's follow-up. c) Provide the client with oral penicillin that will last for 5 days. d) Administer one intramuscular injection of penicillin.
Administer one intramuscular injection of penicillin. 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 antibiotic of choice utilized in the treatment of acute bacterial rhinosinusitis (ABRS) includes which of the following? a) Ceftin (Cefuroxime) b) Levofloxacin (Levaquin) c) Amoxicillin (Augmentin) d) Keflex (Cephalexin)
Amoxicillin (Augmentin) Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanate (Augmentin) is the antibiotic of choice. For patients who are allergic to penicillin, doxycycline (Vibramycin) or respiratory quinolones, such as levofloxacin (Levaquin) or moxifloxacin (Avelox), can be used. Other antibiotics previously prescribed to treat ABRS, including cephalosporins such as cephalexin (Keflex) and cefuroxime (Ceftin), are no longer recommended as they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.
A patient 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 patient about? a) Cefuroxime (Ceftin) b) Clarithromycin (Biaxin) c) Amoxicillin-clavulanic acid (Augmentin) d) Cephalexin (Keflex)
Amoxicillin-clavulanic acid (Augmentin) Treatment of acute rhinosinusitis depends on the cause; a 5- to 7-day course of antibiotics is prescribed for bacterial cases (Chow et al., 2012). 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 (Chow et al., 2012).
A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis? a) Apply direct continuous pressure. b) Apply a moustache dressing. c) Provide a nasal splint. d) Place the client in a semi-Fowler's position.
Apply direct continuous pressure. 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 you perform when caring for a client with epistaxis? a) Apply direct continuous pressure. b) Place the client in a semi-Fowler's position. c) Provide a nasal splint. d) Apply a moustache dressing.
Apply direct continuous pressure. 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.
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? a) Audible stridor without using a stethoscope b) Diminished breath sounds throughout c) Rhonchi in the bronchial region d) Crackles in the bases of the lungs
Audible stridor without using a stethoscope 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? a) Assess capillary refill. b) Auscultate lung sounds. c) Obtain vital signs. d) Monitor heart rhythm.
Auscultate lung sounds. 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 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 a) Wait 10 seconds before administering the second spray. b) Blow the nose before applying medication into the nares. c) Clean the medication container once each day. d) Tilt the head back when activating the spray of the medication.
Blow the nose before applying medication into the nares. 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 is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care? a) Encourage oral nutrition on the second postoperative day. b) Assess the tracheostomy cuff for leaks. c) Develop an alternate method of communication. d) Maintain the client in a low-Fowler's position.
Develop an alternate method of communication. The client with a total laryngectomy is not able to speak. Communication needs to be established using an alternate method. The client typically has difficulty with swallowing due to edema in the immediate postoperative period. Alternate forms of nutrition are used. The tracheostomy cuff is often deflated for periods of time. The head of the bed is maintained in a semi-Fowler's position to decrease edema.
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? a) Partial laryngectomy b) Hemilaryngectomy c) Total laryngectomy d) Supraglottic laryngectomy
Partial laryngectomy 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 herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of a) 3 to 6 months. b) 20 to 30 days. c) 0 to 3 months. d) 2 to12 days.
2 to12 days. HSV-1 is transmitted primarily by direct contact with infected secretions. The time period 0 to 3 months exceeds the incubation period. The time period 20 to 30 days exceeds the incubation period. The time period 3 to 6 months exceeds the incubation period.
Your client has had laryngeal surgery. What is as expected outcome in this client? a) The client maintains an adequate caloric intake. b) The client can swallow without difficulty. c) The client's breathing patterns improve. d) The client's suture line remains intact.
The client maintains an adequate caloric intake. The caloric and fluid intake of a client undergoing laryngeal surgery should be adequate. The suture line and 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 surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: a) A permanent tracheal stoma would be necessary. b) A portion of the vocal cord was removed. c) One vocal cord was removed along with a portion of the larynx. d) The voice was spared and a tracheostomy would be in place until the airway was established.
A permanent tracheal stoma would be necessary. 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 patient is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include a) a moist cough. b) a throat that feels worse in the evening. c) a nonedematous uvula. d) hoarseness.
hoarseness. Signs of acute laryngitis include hoarseness or aphonia and severe cough. Other signs of acute laryngitis include a dry cough, and a throat that feels worse in the morning. If allergies are present, the uvula will be visibly edematous.
A client exhibits a sudden and complete loss of voice and is coughing. The nurse states a) "The 'tickle' in your throat will improve with cold liquids." b) "Do not smoke and avoid being around others who are smoking." c) "Do not use a humidifier; it will make your problem worse." d) "It is fine to speak in a whisper. This does not strain your voice."
"Do not smoke and avoid being around others who are smoking." 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.
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room? a) A rigid shell b) A ventilator c) A nasal cannula d) A face mask
A face mask A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device.
A first-line antibiotic utilized in the treatment of acute sinusitis includes a) Ampicillin b) Ceftin c) Cefzil d) Augmentin
Ampicillin First-line antibiotics include amoxicillin, ampicillin, and erythromycin. Second-line therapy includes Ceftin, Cefzil, and Augmentin.
The nurse should advise the patient who has nasal packing for epistaxis that the packing can be left in place: a) No longer than 2 hours. b) An average of 24 hours. c) Anywhere from 2 to 6 days. d) An average of 12 hours.
Anywhere from 2 to 6 days. If the origin of the bleeding cannot be identified, the nose may be packed with gauze impregnated with petrolatum jelly or antibiotic ointment. The packing may remain in place for 48 hours or up to 5 to 6 days if necessary to control bleeding.
The nurse is caring for a patient admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been completed. Which of the following interventions should the nurse include in the patient's care? a) Position the patient in the side-lying position. b) Restrict fluid intake. c) Apply an ice pack. d) Apply pressure to the convex of the nose.
Apply an ice pack. Following a nasal fracture, the nurse applies ice and encourages the patient to keep the head elevated. The nurse instructs the patient 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 patient 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.
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? a) Auscultate lung sounds. b) Monitor heart rhythm. c) Assess capillary refill. d) Obtain vital signs.
Auscultate lung sounds. 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 of the following is the most effective treatment for obstructive sleep apnea (OSA)? a) Continuous positive airway pressure (CPAP) b) Oxygen by nasal cannula c) Bilevel positive airway pressure (BiPAP) d) Mechanical ventilation
Continuous positive airway pressure (CPAP) CPAP is the most effective treatment for OSA because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient must be breathing independently. BiPAP ventilation offers independent control of inspiratory and expiratory pressure while providing pressure support ventilation. Mechanical ventilation is not the most effective treatment for OSA. Administration of low-flow nasal oxygen at night can help relieve hypoxemia in some patients but has little effect on the frequency or severity of apnea.
The nurse is caring for a male patient diagnosed with rhinosinusitis. The physician has ordered the patient to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the patient that a common side effect of this medication includes which of the following? a) Arthralgia b) Epistaxis c) Headache d) Watery eyes
Epistaxis Common side effects of budesonide include epistaxis, pharyngitis, cough, nasal irritation, and bronchospasms.
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) Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation c) Acute pain related to upper airway irritation secondary to an infection d) Deficient knowledge regarding prevention of upper airway infections, treatment regimens, the surgical procedure, or postoperative care
Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation Ineffective airway clearance can lead to respiratory depression, which necessitates immediate intervention.
The nurse is caring for a patient who underwent a laryngectomy. Which of the following interventions will the nurse initially complete in an effort to meet the patient's nutritional needs? a) Initiate enteral feedings. b) Encourage sweet foods. c) Offer plenty of thin liquids. d) Liberally season foods.
Initiate enteral feedings. Postoperatively, the patient 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 patient is permitted to resume oral feedings, thin liquids are offered, and sweet food are avoided because they cause increased salivation and decrease the patient's appetite. The patient'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 patient usually accommodates to this change and olfactory sensation adapts; thus, seasonings are based on personal preferences.
Stiffness of the neck or inability to bend the neck is referred to as which of the following? a) Aphonia b) Nuchal rigidity c) Dysphagia d) Xerostomia
Nuchal rigidity Nuchal rigidity is the stiffness of the neck or inability to bend the neck. Aphonia is impaired ability to use one's voice due to distress or injury to the larynx. Xerostomia is dryness of the mouth from a variety of causes. Dysphagia is difficulty swallowing.
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 a) Exerts pressure against the worker's abdomen b) Stands behind the worker, who has hands across the neck c) Makes a fist with one hand with the thumb outside the fist d) Places both arms around the worker's waist
Stands behind the worker, who has hands across the neck 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 providing discharge instructions for a patient following laryngeal surgery. The nurse instructs the patient to avoid which of the following? a) Coughing b) Swimming c) Wearing a scarf over the stoma d) Wearing a plastic bib while showering
Swimming Swimming is not recommended because a person 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 patient wear a scarf over the stoma to make the opening less obvious. The nurse encourages the patient to cough every 2 hours to promote effective gas exchange.
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? a) When the drainage tube comes out b) When the patient states that there is discomfort and requests removal c) In 1 week when the patient no longer has serous drainage d) When the patient has less than 30 mL for 2 consecutive days
When the patient has less than 30 mL for 2 consecutive days 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.
A patient diagnosed 2 weeks ago with acute pharyngitis comes to the clinic stating that the sore throat got better for a couple of days and is now back along with an earache. What complications should the nurse be aware of related to acute pharyngitis? (Select all that apply.) a) Peritonsillar abscess b) Otitis media c) Mastoiditis d) Pericarditis e) Encephalitis
• Otitis media • Mastoiditis • Peritonsillar abscess Uncomplicated viral infections usually subside promptly, within 3 to 10 days after onset. However, pharyngitis caused by more virulent bacteria, such as GAS, is a more severe illness. If left untreated, the complications can be severe and life threatening. Complications include rhinosinusitis, otitis media, peritonsillar abscess, mastoiditis, and cervical adenitis. In rare cases, the infection may lead to bacteremia, pneumonia, meningitis, rheumatic fever, and nephritis.
The nurse assesses a patient for possible acute pharyngitis. Which of the following clinical manifestations are consistent with this diagnosis? Select all that apply. a) A dry, nonproductive cough b) Red pharyngeal membranes c) A temperature >100.4°F d) Swollen lymphoid follicles e) White-purple exudates on the back of the throat
• Red pharyngeal membranes • Swollen lymphoid follicles • White-purple exudates on the back of the throat • A temperature >100.4°F Acute pharyngitis is not characterized by a cough. All the other symptoms are present.
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? a) Post operative bleeding b) Edema of the upper airway c) Infection d) Plugged tracheostomy tube
Edema of the upper airway 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 client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice? a) Radiation therapy b) Partial laryngectomy c) Laser surgery d) Total laryngectomy
Total laryngectomy In more advanced cases, total laryngectomy may be the treatment of choice. Partial laryngectomy, laser surgery, and radiation therapy are not the treatment of choice for advanced cases of laryngeal cancer.
A 72-year-old male client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. If laryngeal cancer is suspected, the nurse would be most likely to hear which of the following complaints from the client? a) Discomfort when drinking cold liquids b) Headaches in the morning c) A feeling of swelling at the back of the throat d) Weight loss
A feeling of swelling at the back of the throat 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 complain of burning in the throat when swallowing hot or citrus liquids. Clients with obstructive sleep apnea may experience a morning headache.
