NUR 222 - Ch 9 - PrepU
A client has had a laryngectomy as treatment for laryngeal cancer. Which postoperative instruction is of utmost importance to the client's health and safety?
avoid swimming (p. 265)
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
What client would be most in need of an endotracheal tube?
Comatose clients (p. 266)
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
Noisy breathing
A 48-year-old client has just undergone surgery for a nasal obstruction. Which of the following nursing interventions should you, as his nurse, perform to promote the client's safety and recuperation?
Ensure mouth breathing of your 48 year old Patient. (p. 257)
The nurse expects that emergency medical treatment for epistaxis may include insertion of a cotton pledget moistened with:
Epinephrine (p. 256)
A client exhibits a sudden and complete loss of voice and is coughing. The nurse states
"Do not smoke and avoid being around others who are smoking." (p. 251)
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?" (Page 249)
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." (p. 262)
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." (p. 254)
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 surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:
A permanent tracheal stoma would be necessary. (p. 260)
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?
Amoxicillin-clavulanic acid (Augmentin)
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. (p. 256)
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 (p. 257)
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.
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?
Bleeding (p. 256)
Which of the following is an early complication of tracheostomy tube management? Select all 3 that apply.
Bleeding; Air embolism; Subcutaneous emphysema (pp. 266-267)
Which of the following nursing interventions should a nurse perform when caring for a patient with an endotracheal tube?
Clean teeth with applicators (p. 269)
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.
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 in your 42 year old patient (p. 266)
Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require?
Emotional support (p. 264)
You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis?
Encourage deep breathing every 2 hours. (Page 262)
Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?
Ensure mouth breathing of the patient who has undergone surgery for a nasal obstruction (p. 257)
You are speaking at a local PTO meeting about upper respiratory infections. Which preventive factor for rhinitis should you teach the attendees?
Get adequate rest and sleep. (pp. 246-248)
During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?
Hypercapnia
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 (p. 252)
Which of the following are *5* clinical manifestations associated with obstructive sleep apnea (OSA)? Select all that apply.
Insomnia; Arrhythmias; Loud snoring; Excessive daytime sleepiness; Impotence (pp. 253-254)
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 cancer (p. 260)
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 (p. 253)
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 (1 vocal cord involved) (p. 260)
Which of the following is a complication of low cuff pressure on an endotracheal tube?
Risk of aspiration (p. 266)
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 (p. 251)
You are a clinic nurse caring for a client who is 2 months post laryngectomy. What is a nursing diagnosis pertaining to this client?
Social Isolation related to change in body image, tracheal stoma, and change in or loss of speech (p. 264)
You are performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would you ask the client about the use of herbal supplements?
They prolong bleeding.
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
Total laryngectomy (Page 260-261)
A client has had a laryngectomy as treatment for laryngeal cancer. Which nutritional interventions should be implemented for the client?
Use enteral feedings after the procedure. (p. 263)
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:
laryngeal cancer is one of the most preventable types of cancer. (Page 258)
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
the highest priority nursing Dx is Ineffective airway clearance related to excess mucus production (p. 252)
Wound drains, inserted during the laryngectomy, stay in place until what criteria are met?
Drainage is <30 mL/day for 2 consecutive days. (p. 263)
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?
Edema of the upper airway in the client in severe respiratory distress
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 (retained airway) (p. 260)
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
