Ch 22: Management of Patients with Upper Respiratory Tract Disorders

keep the stoma moist

A client undergoes a laryngectomy to treat laryngeal cancer. What instruction should the nurse include in the teaching about the neck stoma?

avoid air travel

A client with acute viral rhinosinusitis is being seen in a clinic. The nurse is providing discharge instructions and includes the following information:

sit upright, leaning slightly forward

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:

20 mL or less

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with 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?

laryngeal cancer

A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?

apply direct continuous pressure

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

a feeling of swelling in the back of the throat

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?

fever

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:

nuchal rigidity

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

"Gargle with a warm salt solution."

A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client?

the ET tube will maintain your airway while you're under anesthesia

A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube?

ineffective airway clearance related to excess mucus production

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

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

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?

amoxicillin-clavulanic acid

A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is

seek medical help if he experiences inability to swallow

A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to

retractions in the neck during inspiration

A nurse is caring for a client experiencing laryngeal obstruction. What clinical finding should lead the nurse to anticipate mechanical ventilation for the client?

"I should become involved in a weight loss program."

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:

stands behind the worker

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

hoarseness of more than 2 week's duration

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.

Group A, beta-hemolytic streptococcus

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?

the nasal mucosa

A patient comes to the clinic complaining of a possible upper respiratory infection. What should the nurse inspect that would indicate that an upper respiratory infection may be present?

partial laryngectomy

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?

an antiviral agent such as acyclovir

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?

a permanent tracheal stoma would be necessary

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

placing the client prone with the head turned to the side

A young adult client has had a tonsillectomy and is in the immediate postoperative period. To make the client comfortable, the nurse intervenes by

2-12 days

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

epistaxis

The nurse assesses a client who is bleeding profusely from the nose. The nurse documents this finding as which condition?

apply an ice pack

The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care?

edema of the upper airway

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?

develop an alternate method of communication

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

administer an over the counter decongestant

The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?

initiate enteral feedings

The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs?

auscultate lung sounds

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?

hoarseness for 2 weeks

The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?

"I was chewing ice chips all day long."

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?

swimming

The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid

avoid sports activities for 6 weeks

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

carotid artery hemorrhage

When a client has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the client very carefully because of the high risk for

ensure mouth breathing

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