Ch 22
A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with a 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?
20-25 mL
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?
Partial laryngectomy
The nurse is assessing a client in the clinic, and upon physical assessment the client demonstrates displacement of the sternum. This would be documented as which condition?
Pigeon chest
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 of the following is the most effective treatment for obstructive sleep apnea (OSA)?
Continuous positive airway pressure (CPAP)
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
A patient is diagnosed as being in the early stage of laryngeal cancer of the glottis with only 1 vocal cord involved. For what type of surgical intervention will the nurse plan to provide education?
Partial laryngectomy
The nurse assesses a patient for possible acute pharyngitis. Which of the following clinical manifestations are consistent with this diagnosis? Select all that apply.
Red pharyngeal membranes Swollen lymphoid follicles White-purple exudates on the back of the throat A temperature >100.4°F
A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client:
Sleep with the head of bed elevated.
A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever, and dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may predispose the client to sinusitis?
interference with sinus drainage
The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed?
When the patient has less than 30 mL for 2 consecutive days
A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is
Ineffective airway clearance related to excess mucus production
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
When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided?
Swimming
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of
2 to 12 days
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."
A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube?
"The ET tube will maintain your airway while you're under anesthesia."
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:
A permanent tracheal stoma would be necessary.
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
Total laryngectomy
Most cases of acute pharyngitis are caused by which of the following?
Viral infection
The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?
Develop an alternate method of communication.
A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is considered an early clinical indicator.
Hoarseness of more than 2 week's duration
A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include
hoarseness.
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of
2 to 12 days.
A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to
Seek medical help if he experiences inability to swallow
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 nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?
impaired verbal communication
Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)?
Amoxicillin
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
The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply.
Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 Increased respiratory effort Nasal flaring with abdominal retractions Lung sounds of wheezing
