Chapter 22 (Test 3)

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

The nurse advises a patient who sustained a fractured nose during an automobile accident that surgery will be necessary. Due to significant facial edema, surgery would be scheduled:

Within 1 week.

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 • Lung sounds of stridor • Nasal flaring with abdominal retractions

Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?

"Because I had a previous reaction to the test, this time I need to get a chest X-ray."

A client seeks care for hoarseness that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question?

"Do you smoke cigarettes, cigars, or a pipe?"

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

A permanent tracheal stoma would be necessary.

The antibiotic of choice utilized in the treatment of acute bacterial rhinosinusitis (ABRS) includes which of the following?

Amoxicillin (Augmentin)

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

Sinus aspirates

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

Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and an increase in the death rates of pneumonia and cardiovascular disease. Besides death, what is the most serious complication of influenza?

Staphylococcal pneumonia

Which of the following postoperative instructions does a nurse provide a patient and family to avoid after a laryngeal surgery?

Swimmingf

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°." This assists in meeting which nursing goal?

The client will have decreased edema.

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?

Audible stridor without using a stethoscope

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?

Auscultate lung sounds.

The nurse is providing discharge instructions to a patient following nasal surgery who has nasal packing. Which of the following discharge instructions would be most appropriate for the patient?

Avoid sports activities for 6 weeks

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?

Blood-tinged sputum

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 recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

Developing a list of people with whom the client has had contact

A client is being seen by the physician because of her unrelenting headache, facial tenderness, low-grade fever, and dark yellow nasal discharge. The client states that she seems to develop sinus infections "all the time." The nurse instructs the client that which of the following may predispose her to sinusitis?

Interference with sinus drainage

Which of the following medications is the treatment of choice for bacterial pharyngitis?

Penicillin

When a patient has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the patient very carefully because he or she is at high risk for

carotid artery hemorrhage.

A client is being discharged from an outpatient surgery center following a tonsillectomy. The nurse gives the following instructions:

"Gargle with a warm salt solution."

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."

A 42-year-old female client is scheduled for endotracheal intubation prior to her surgery. Which of the following can the nurse instruct this client?

"The ET tube will maintain your airway while you're under anesthesia."

A college student presents to the health clinical with signs and symptoms of viral rhinitis (common cold). The patient states, "I've felt terrible all week; what can I do to feel better?" Which of the following is the best response the nurse can give?

"You should rest, increase your fluids, and take Ibuprofen."

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of which of the following?

2 to 12 days

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

A client comes into the emergency department with epistaxis. What intervention should you perform when caring for a client with epistaxis?

Apply direct continuous pressure

Which of the following is a priority nursing intervention that the nurse should perform for a patient who has undergone surgery for a nasal obstruction?

Ensure mouth breathing

A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for:

Fever

You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Fibrotic changes in lungs

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

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 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

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

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?

Initiate enteral feedings

A 62-year-old male client with a history of chronic laryngitis arrives at the clinic complaining of a hoarseness "he can't shake." The nurse is aware that this client may be at risk for which of the following conditions?

Laryngeal cancer

A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for

Nuchal rigidity