Med-Sur Respiratory 1-13

A nurse is caring for a client who is 1-day postoperative following a total laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse that the hospital food has no taste. Which of the following responses is appropriate for the nurse to make?

"Because of your surgery, you have an altered ability to smell and taste." Rationale: Clients who have lost their larynx commonly complain of poor ability to smell and taste. This is because they now breathe through the tracheal stoma, rather than the mouth and nose, which bypasses the location of the olfactory and gustatory nerve cells.

9.A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I will wear synthetic clothing and woolen socks when using my oxygen." Rationale: Woolen and synthetic materials can generate static electricity. Because oxygen is a flammable gas, the client should wear cotton clothing and use cotton bedding and blankets.

A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make?

"It is no longer possible for you to choke on or aspirate food." Rationale: The surgical procedure of total laryngectomy provides complete anatomical separation of the

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

A. Attach a humidifier bottle to the base of the flow meter.

A nurse is preparing to suction a client who has a tracheostomy. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

A. Adjust the suction. C. Don sterile gloves. D. Check the function of the suction catheter. F. Hyperoxygenate the client. E. Insert the catheter without suction. B. Apply suction while rotating the catheter. Assess for secretion clearance.

A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

Airway patency. Rationale: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority assessment is airway patency. After head and neck surgery, a major, life-threatening complication is airway obstruction. The priority actions involve airway maintenance and gas exchange.

A nurse in the emergency department is assessing a newly admitted client who has facial trauma. Which of the following assessments is the nurse's priority?

Altered respirations

A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take? (Select all that apply.)

Apply pressure to the nares. B. Place ice to the bridge of the client's nose. E. Move the client into high-Fowler's position.

11.A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply.)

B. Check the cannula position on a regular basis. C. Check the tops of the ears for skin breakdown. D. Post "no smoking" signs in a prominent location in the home.

A nurse is preparing to provide tracheostomy care for a client who has a non-disposable tracheostomy tube. Which of the following equipment should the nurse plan to use? (Select all that apply.)

B. Clean gloves D. Sterile cotton-tipped applicators E. Sterile basin. Rationale:Sterile cotton balls is incorrect. The nurse should avoid using sterile cotton balls when providing tracheostomy care as cotton lint can be aspirated by the client. Clean gloves is correct. The nurse will use clean gloves to remove the soiled tracheostomy dressing

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

Clear breath sounds Rationale: Clear breath sounds indicate that there are no remaining secretions obstructing or potentially obstructing the client's airway.

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following?

Delivers a low concentration of oxygen. Rationale:A nasal cannula delivers a relatively low concentration of oxygen (24% to 44%).

A nurse is assessing a client who has obstructive sleep apnea. Which of the following findings should the nurse expect?

Headache. Rationale: Obstructive sleep apnea can cause morning headache, fatigue, irritability, snoring, and restlessness.

A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client's care?

Need for suctioning. Rationale: Using the airway, breathing, circulation (ABC) priority-setting framework, confirming a patent airway is the priority observation for a postoperative client after a total laryngectomy.

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Perform tracheostomy care for the client every 4 hr. Rationale: The nurse should perform tracheostomy care every 4 hr to reduce the risk of infection.

A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?

Performing the procedure independently. Rationale: The nurse should recognize that the client is ready for discharge when the spouse demonstrates an ability to perform the procedure that will need to be performed independently at home.

A nurse is caring for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take?

Provide humidified air for the client.

A nurse is planning the discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BiPAP) at night. The nurse should plan to consult with which of the following health care team members to help educate the client?

Respiratory therapist. Rationale: Respiratory therapists help clients learn to use oxygenation and airway management devices, such as BiPAP equipment.

A nurse is planning care for a client who has a tracheostomy. Which of the following interprofessional team members should the nurse anticipate a provider's prescription for a referral to manage the client's tracheostomy?

Respiratory therapist. Rationale: The nurse should plan to refer the client to respiratory therapy services. A respiratory therapist can assist with maintaining the client's ventilation by managing their tracheostomy.

A nurse is caring for a client who has a tracheostomy. Which of the following interventions should the nurse implement when performing tracheostomy care?

Secure new tracheostomy ties before removing old ones.

A nurse is teaching a client who has a prescription for home oxygen therapy. Which of the following instructions should the nurse include?

Store oxygen tanks upright. Rationale: Oxygen tanks should be stored upright and attached to a fixed object to prevent them from falling over.

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Suction two to three times with a 60-second pause between passes. Rationale: Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was

hoarseness.