CH 22-Med surg
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." Explanation: A warm saline solution will help with removal of thick mucus and halitosis. It will be a gentle gargle, because a vigorous gargle may cause bleeding. A sore throat may be present for 3 to 5 days. Hot foods should be avoided.
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." Explanation: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea.
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." Explanation: Management of viral rhinitis consists of symptomatic therapy that includes adequate fluid intake, rest, prevention of chilling, and use of expectorants as needed. Warm saltwater gargles soothe the sore throat, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, relieve aches and pains. Antibiotics are not prescribed because they do not affect the virus causing the patient's signs and symptoms. Topical nasal decongestants should be used with caution. The symptoms of viral rhinitis may last from 1 to 2 weeks.
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. Explanation: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction.
A client with acute viral rhinosinusitis is being seen in a clinic. The nurse is providing discharge instructions and includes the following information:
Avoid air travel. Explanation: Information that the nurse should include for a client with acute viral rhinosinusitis is to avoid air travel. Other nursing interventions include referring the client to a physician if severe pain occurs when palpating the sinuses and humidifying the air in the home to promote drainage. Antibiotic therapy is not indicated for a viral infection
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. Explanation: The nurse instructs the patient to avoid sports activities for 6 weeks. There is no indication for the patient to refrain from taking oral fluids. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. The patient should take analgesic agents, such as acetaminophen or NSAIDs, (i.e., ibuprofen or naproxen) to decrease nasal discomfort, not aspirin. The patient does not need to use nasal drops when nasal packing is in place.
A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to
Check the clear fluid for glucose. Explanation: The client's signs and symptoms are consistent with a fracture of the nose. Clear fluid draining from either nostril suggests leakage of cerebrospinal fluid. This can be checked by assessing for glucose, which is in cerebrospinal fluid. This finding is important to identify, because infection can be transmitted through the opening in the cribiform plate. Other options, such as applying an ice pack to the nose and administering ibuprofen, are appropriate interventions but not most important for this client. Reassuring the client that the nose is not fractured is premature until all assessments are completed.
The nurse knows that there are three types of chronic pharyngitis. Which of the following is characterized by numerous swollen lymph follicles on the pharyngeal wall?
Chronic granular Explanation: Chronic granular pharyngitis is characterized by numerous swollen lymph follicles on the pharyngeal wall. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane.
Which assessment finding puts a client at increased risk for epistaxis?
Cocaine use Explanation: Using nasally inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased vascularity of the nasal passages. A dry environment (not a humidified one) increases the risk of epistaxis. Hypertension, not hypotension, increases the risk of epistaxis. A history of nasal surgery doesn't increase the risk of epistaxis.
Which of the following nursing diagnoses best encompasses the anticipated psychosocial concerns of a client who is scheduled for a laryngectomy?
Disturbed body image Explanation: Loss of the ability to speak normally is a devastating consequence of laryngeal surgery. Clients with a malignancy of the larynx require emotional support before and after surgery and help in understanding and choosing an alternative method of speech. Clients require information prior to their surgery to make appropriate decisions, but this is not considered a psychosocial concern. Clients are at high risk for infection following a laryngectomy, but this is not considered a psychosocial concern. Although chronic low self-esteem may develop following a laryngectomy, depending on the client's ability to cope, a more immediate concern would be related to disturbed body image.
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 Explanation: The principal causes are the spread of an infection from the nasal passages to the sinuses and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis because trapped secretions readily become infected. Client with persistent sinus infections may have allergies, nasal polyps, or a deviated septum. Eating a well-balanced diet that includes but does not rely exclusively on protein is a measure that may help reduce incidences of sinusitis. Getting plenty of rest is a measure that may help reduce incidences of sinusitis. This is not a specific cause of sinusitis, which is more commonly caused by allergies or blockage of the nasal passages.
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 Explanation: The nurse knows that laryngeal cancer is most common in people 60 to 70 years of age, with men affected more frequently than are women. The client's history of chronic laryngitis may also predispose him to the development of laryngeal cancer. Sore throat, difficulty or pain on swallowing, fever, and malaise are the most common symptoms of adenoiditis. Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. This is another term for the common cold. Symptoms include sneezing, sore throat, and nasal congestions. Clients with a peritonsillar abscess experience difficulty and pain with swallowing, fever, malaise, ear pain, and difficulty talking.
A client who has been diagnosed with an early glottis cancer would most likely undergo which type of surgery?
Laser microsurgery Explanation: In early glottis cancer, early stage lesions are treated and removed with a laser process. This would be the surgical treatment for early stage vocal cord lesions. This surgery is done to treat early-stage laryngeal cancer when only one cord is involved. This surgery is done when the cancer extends beyond the vocal cords.
The nurse is caring for a female patient following a tonsillectomy and adenoidectomy. Two hours following the procedure, the patient begins to vomit large amounts of dark blood in frequent intervals and is tachycardic and febrile. After notifying the surgeon, the nurse will do which of the following?
Obtain a light, mirror, gauze, curved hemostats. Explanation: If the patient vomits large amounts of dark blood at frequent intervals, or if the pulse rate and temperature rise, or the patient becomes restless, the nurse notifies the surgeon immediately. The nurse should have the following items ready for examination of the surgical site for bleeding: a light, a mirror, gauze, curved hemostats, and a waste basin. It is not necessary for the nurse to stay at the patient's bedside. Needle aspiration is a procedure considered for patients experiencing a peritonsillar abscess. Although oral suctioning may be needed at some point of care, it is not a priority at this time.
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 Explanation: In a partial laryngectomy, a portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing. During a supraglottic laryngectomy, a tracheostomy is left in place until the glottic airway is established. Hemilaryngectomy is done by splitting the thyroid cartilage of the larynx in the midline of the neck, and the portion of the vocal cord is removed with the tumor. During a total laryngectomy, a complete removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea.
A patient who has an altered level of consciousness is receiving tube feedings. Patients receiving tube feeding should be placed in which of the following positions?
Semi-Fowler's or higher Explanation: Patients receiving tube feedings are positioned with the head of the bed at 30 degrees or higher during feedings and for 30 to 45 minutes after tube feedings. Patients receiving oral feedings are positioned with the head of the bed in an upright position for 30 to 45 minutes after feedings. For patients with a nasogastric or gastrostomy tube, the placement of the tube and residual gastric volume must be checked before each feeding.
The nurse is caring for a patient in the ICU with a nasotracheal tube. Because of the tube placement, the nurse understands that the patient is at risk for developing which of the following?
Sinus infection Explanation: Patients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Thus, accurate assessment of patients with these tubes is critical. Removal of the nasotracheal or nasogastric tube as soon as the patient's condition permits allows the sinuses to drain, possibly avoiding septic complications. Severe epistaxis is not a complication of nasotracheal placement. Subperiosteal abscess and orbital cellulitis are complications of chronic rhinosinusitis.
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 Explanation: The description of the fellow worker is a person who is choking. Following guidelines set by the American Heart Association, the nurse first stands behind the person who is choking.
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?
Sudden restlessness Explanation: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube. A harsh cough and rhonchi in the lung fields is common with the presence of mucous secretions.
A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by
Telling the client to sit upright with the head tilted forward Explanation: Hemorrhage or massive bleeding from the nose is called epistaxis. Initial interventions include having the client sit upright with the head tilted forward to prevent swallowing and aspiration of blood. Tilting the head back will encourage the client to swallow and possibly aspirate blood. Pressure is applied to the soft outer portion of the nose against the midline septum, not the upper and hard portion of the nose. Pressure is also applied continuously for 5 to 10 minutes.
When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?
Test the nasal drainage for glucose. Explanation: Because cerebrospinal fluid (CSF) contains glucose, testing nasal drainage for glucose helps determine whether it's CSF. The nurse should look for a halo sign only if the drainage is blood tinged. A client with a suspected CSF leakage shouldn't blow his nose; doing so could increase the risk of injury. The nurse should contact the physician after completing the assessment.
Your client has had laryngeal surgery. What is as expected outcome in this client?
The client maintains an adequate caloric intake. Explanation: The caloric and fluid intake of a client undergoing laryngeal surgery should be adequate. The suture line and swallowing abilities are evaluated in clients undergoing tonsillectomy and adenoidectomy. Improved breathing patterns are evaluated in the case of clients with trauma in the upper airway.
Clients who have had a laryngectomy are devastated by their loss of the ability to speak normally. Why should a nurse provide extra time and support with these clients?
These clients need support and help in understanding and choosing an alternative method of speech. Explanation: Loss of the ability to speak normally is a devastating consequence of laryngeal surgery. Clients with a malignancy of the larynx require emotional support before and after surgery and help in understanding and choosing an alternative method of speech. A client going for a tracheostomy may become confused after the procedure. Clients with sleep apnea require instructions to use CPAP.
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
Total laryngectomy Explanation: In more advanced cases, total laryngectomy may be the treatment of choice. Partial laryngectomy, laser surgery, and radiation therapy are not the treatment of choice for advanced cases of laryngeal cancer.
The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose?
Transillumination of the sinus Explanation: Transillumination and x-rays of the sinuses may show a change in the shape of or confirms that there is fluid in the sinus cavity. CBC with differential can note an elevated white blood cell count but not confirm fluid in the sinus cavity. A nasal culture can note bacteria in the nares. An MRI is an expensive procedure which is not typically prescribed for a potential infection and not specifically ordered to identify fluid in the sinus cavity
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. Explanation: Laryngeal cancer is one of the most preventable types of cancer; it can be prevented by abstaining from excessive drinking and smoking. Inhaling noxious fumes, such as in polluted air, is a risk factor for laryngeal cancer. Roughly 80% of laryngeal cancer cases occur in men. Squamous cell carcinoma accounts for most cases of laryngeal cancer.
You are mentoring a new graduate nurse. Today, the two of you are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would you respond? Select all that apply.
• Aspiration • Infection • Injury to the laryngeal nerve Explanation: The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall.
Late symptoms of laryngeal cancer include which of the following. Select all that apply.
• Dysphagia • Dyspnea • Persistent hoarseness Explanation: Later symptoms include dysphagia, dyspnea, unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath. Earlier, the patient may complain of a persistent cough or sore throat and pain and burning in the throat, especially when consuming hot liquids or citrus juices.
Late complications of radiation therapy may include which of the following? Select all that apply.
• Laryngeal necrosis • Edema • Fibrosis Explanation: Complications occurring late may include laryngeal necrosis, edema, and fibrosis. Loss of taste and xerostomia are symptoms of radiation therapy that may occur earlier in treatment.
The nurse is caring for a geriatric client brought to the emergency department after being found by her children feeling poorly with an elevated temperature. Laboratory tests confirm influenza type A, a respiratory virus. Which medical treatment would the nurse anticipate in the discharge instructions? Select all that apply.
• Rest • Increased fluids • Saline gargles • Antitussives Explanation: Influenza type A is the most common cause of the flu initiated by a respiratory virus. Common discharge instructions include rest, increased fluids to thin respiratory secretions, saline gargles to help prevent a throat infection such a strep throat, and antitussives if the client is coughing. Antibiotics are not used with a virus unless a bacterial infection subsequently develops. Antiemetics are used for nausea and vomiting not commonly associated with a common respiratory virus.
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 Explanation: The nurse anticipates hearing audible stridor without needing a stethoscope due to the neck swelling narrowing the airway. Rhonchi in the bronchial region is heard lower in the airways and crackles are heard in the bases of the lungs. Diminished breath sounds that occur throughout are indicative of airway obstruction and not indicative of laryngeal swelling.
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. Explanation: Major goals of intubation are to improve respirations and maintain a patent airway for gas exchange. Regular auscultation of the lung fields is essential in confirming that air is reaching the lung fields for gas exchange. All other options are important to provide assessment data.
Which of the following is the priority nursing diagnosis for the patient undergoing a laryngectomy?
Ineffective airway clearance Explanation: The priority nursing diagnosis is Ineffective airway clearance, utilizing the ABCs. Imbalanced nutrition: Less than body requirement, impaired verbal communication, and anxiety and depression are all potential nursing diagnoses, but they are not the priority diagnosis.
Bleeding from the drains at the surgical site or with tracheal suctioning may signal the occurrence of hemorrhage. Which of the following is a clinical manifestations associated with hemorrhage?
Rapid, deep respirations Explanation: The nurse monitors the vital signs for increased pulse rate, decreased blood pressure, rapid deep respirations, restlessness, and delayed capillary refill. Cold, clammy skin may indicate active bleeding.
A client is experiencing acute viral rhinosinusitis. The nurse is providing instructions about self-care activities and includes information about
Saline lavages to the nares Explanation: Saline lavages are used for acute rhinosinusitis and relieve symptoms, reduce inflammation, clear nasal passages of stagnant mucus, and reduce the development of opportunistic infections. Other methods that promote drainage of the sinuses are humidifying the air, not dehumidifying it, and warm compresses, not cold compresses, to the sinus cavities. Because this infection is viral, antibiotics are not indicated.
The nurse is caring for a client with a new tracheostomy. Which of the following nursing diagnoses are priorities? Select all that apply. a) Impaired Gas Exchange related to shallow breathing and anxiousness b) Knowledge Deficit related to care of the tracheostomy tube and surrounding site c) Ineffective Airway Clearance related to increased secretions d) Risk for Infection related to operative incision and tracheostomy tube placement
• Ineffective Airway Clearance related to increased secretions • Impaired Gas Exchange related to shallow breathing and anxiousness Explanation: The client with a new tracheostomy tube has increased secretions, which may become dried and occlude the airway or plug the airway requiring frequent suctioning. Impaired Gas Exchange is an equally important diagnosis. These are related to airway and breathing and are priorities.
Your client has just been diagnosed with laryngeal cancer. The client asks you what causes laryngeal cancer. What would be your best response?
"Research has shown that heredity contributes to having laryngeal cancer." Explanation: In addition, chronic laryngitis, habitual overuse of the voice, and heredity may contribute. Carbon monoxide has not been associated with laryngeal cancer. Allergies are not a carcinogen.
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. Explanation: The client with a total laryngectomy is not able to speak. Communication needs to be established using an alternate method. The client typically has difficulty with swallowing due to edema in the immediate postoperative period. Alternate forms of nutrition are used. The tracheostomy cuff is often deflated for periods of time. The head of the bed is maintained in a semi-Fowler's position to decrease edema.
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?
Hoarseness for 2 weeks Explanation: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity.
Which of the following clinical manifestations of hemorrhage is related to carotid artery rupture?
Increased pulse rate Explanation: The nurse monitors vital signs for changes, particularly increased pulse rate, decreased blood pressure, and rapid, deep respirations. Cold, clammy, pale skin may indicate active bleeding.
A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in her teaching?
"Cover the stoma whenever you shower or bathe." Explanation: The nurse should instruct the client to gently cover the stoma with a loose plastic bib, or even a hand, when showering or bathing to prevent water from entering the stoma. The client should cover the stoma with a loose-fitting, not tight, cloth to protect it. The client should keep his house humidified to prevent irritation of the stoma that can occur in low humidity. The client should avoid swimming, because it's possible for water to enter the stoma and then enter the client's lung, causing him to drown without submerging his fac
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." Explanation: A sudden and complete loss of voice and cough are symptoms of laryngitis. The nurse instructs the client to avoid irritants, such as smoking. Voice rest is indicated. Whispering places stress on the larynx. Inhaling cool steam or aerosal aids in the treatment. Dry air may make the symptoms worse. A "tickle" in the throat that many clients report is actually worsened with cold liquids.
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?" Explanation: Persistent hoarseness may signal throat cancer, which commonly is associated with tobacco use. To assess the client's risk for throat cancer, the nurse should ask about smoking habits. Although straining the voice may cause hoarseness, it wouldn't cause hoarseness lasting for 1 month. Consuming red meat or spicy foods isn't associated with persistent hoarseness.
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." Explanation: An endotracheal tube provides a patent airway for clients who cannot maintain an adequate airway on their own. Tracheostomy tubes are inserted into a surgical opening in the trachea, called a tracheotomy. Clients receiving endotracheal intubation for the purpose of general anesthesia should not require long-term placement of the ET tube. Positive-pressure ventilators require intubation and are used for clients who are under general anesthesia. They are also used for clients with acute respiratory failure, primary lung disease, or comatose.
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?
"The ET tube will maintain your airway while you're under anesthesia." Explanation: An endotracheal tube provides a patent airway for clients who cannot maintain an adequate airway on their own. Tracheostomy tubes are inserted into a surgical opening in the trachea, called a tracheotomy. Clients receiving endotracheal intubation for the purpose of general anesthesia should not require long-term placement of the ET tube. Positive-pressure ventilators require intubation and are used for clients who are under general anesthesia. They are also used for clients with acute respiratory failure, primary lung disease, or comatose.
The nurse is caring for a client with allergic rhinitis. The patient asks the nurse about measures to help decrease allergic symptoms. The best response by the nurse is which of the following?
"You should try to reduce exposure to irritants and allergens." Explanation: The nurse instructs the patient with allergic rhinitis to avoid or reduce exposure to allergens and irritants, such as dusts, molds, animals, fumes, odors, powders, sprays, and tobacco smoke. Receiving an influenza vaccination each year is recommended for patients with infectious rhinitis. To prevent possible drug interactions, the patient is cautioned to read drug labels before taking any OTC medication. Patients with nasal septal deformities or nasal polyps may be referred to an ear, nose, and throat specialist.
The nurse at an employee wellness clinic is meeting with a client who reports voice hoarseness for more than 2 weeks. To determine if the client may have symptoms of early laryngeal cancer, the next question the nurse should ask is, "Do you have:"
"a persistent cough or sore throat" Explanation: Hoarseness longer than 2 weeks with a persistent cough or sore throat are early symptoms of laryngeal cancer. Later symptoms of laryngeal cancer include dysphagia, dyspnea, and foul breath.
The client is to receive cephalexin (Ancef) 500 mg in 50 mL of normal saline intravenous piggyback. The medication is to infuse over 30 minutes. How many mL/hr would the nurse set the intravenous pump? Enter the correct number ONLY.
100 Explanation: The volume of the IV medication is 50 mL. The time for infusion is 30 minutes or 0.5 hr. 50 mL/0.5 hr = 100 mL/1 hr.
The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?
Administer an over-the-counter decongestant. Explanation: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opens the nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best.
A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority?
Administer one intramuscular injection of penicillin. Explanation: If a nurse is concerned that a client may not perform follow-up treatment for streptococcal pharyngitis, the highest priority is to administer penicillin as a one-time injection dose. Oral penicillin is as effective and less painful, but the client needs to take the full course of treatment to prevent antibiotic-resistant germs from developing. The nurse should provide oral and written instructions for the client, but this is not as high a priority as administering the penicillin. Having a homeless friend monitor the client's care does not ensure that the client will follow therapy
You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently?
Airway patency Explanation: The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation.
The antibiotic of choice utilized in the treatment of acute bacterial rhinosinusitis (ABRS) includes which of the following?
Amoxicillin (Augmentin) Explanation: Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanate (Augmentin) is the antibiotic of choice. For patients who are allergic to penicillin, doxycycline (Vibramycin) or respiratory quinolones, such as levofloxacin (Levaquin) or moxifloxacin (Avelox), can be used. Other antibiotics previously prescribed to treat ABRS, including cephalosporins such as cephalexin (Keflex) and cefuroxime (Ceftin), are no longer recommended as they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.
A first-line antibiotic utilized in the treatment of acute sinusitis includes a) Ampicillin b) Augmentin c) Ceftin d) Cefzil
Ampicillin Explanation: First-line antibiotics include amoxicillin, ampicillin, and erythromycin. Second-line therapy includes Ceftin, Cefzil, and Augmentin.
The nurse is caring for a patient admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been completed. Which of the following interventions should the nurse include in the patient's care?
Apply an ice pack. Explanation: Following a nasal fracture, the nurse applies ice and encourages the patient to keep the head elevated. The nurse instructs the patient to apply ice packs to the nose to decrease swelling. The packing inserted to stop the bleeding may be uncomfortable and unpleasant, and obstruction of the nasal passages by the packing forces the patient to breathe through the mouth. This, in turn, causes the oral mucous membranes to become dry. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. Applying direct pressure is not indicated in this situation.
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?
Bleeding Explanation: The nurse should instruct the client to report bleeding immediately. Delayed bleeding may occur when the healing membrane separates from the underlying tissue — usually 7 to 10 days postoperatively. Difficulty swallowing and throat pain are expected after a tonsillectomy and typically are present even before the client is discharged. Sudden difficulty talking wouldn't occur after discharge if the client could talk normally at the time of discharge, because swelling doesn't take that long to develop.
Which of the following methods most resembles normal speech following a total laryngectomy? a) Esophageal speech b) Electrolarynx held at neck c) Lip speaking d) Blom-Singer voice prosthesis
Blom-Singer voice prosthesis Explanation: The Blom-Singer voice prosthesis most resembles normal speech. With esophageal speech, patients compress air into the esophagus and expel it, setting off a vibration of the pharyngeal esophageal segment. With electrolarynx, a battery-powered apparatus projects sound into the oral cavity. When the mouth forms words (articulation), the sounds from the electric larynx becomes audible words. Lip speaking is available during the immediate postoperative period. It does not resemble normal speech.
A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to
Blow the nose before applying medication into the nares. Explanation: The nurse instructs the client to blow the nose before administering the nasal medication. The client should keep the head upright, not tilted back. The client should wait at least 1 minute before administering the second spray and clean the container after each use
Clients Previously Assigned to Rooms Client A who is HIV positive adn has acute pharyngitis Client B who is receiving an IV infusion of crystalloid solution following epistaxis Client C who has primary bleeding following a tonsillectomy Client D who had a total laryngectomy and is receiving enteral feedings The nurse is to make a room assignment for a client diagnosed with an upper respiratory infection. The other clients with empty beds in the room are listed in the accompanying chart. The best room assignment for the new client would be with Client a) A b) B c) C d) D
Client B Explanation: The nurse needs to make the appropriate room assignment based on the client's problems, safety, and risk for infection to others. The client with an upper respiratory infection may transmit infection to susceptible people. Clients A, C, and D have increased susceptibility for infection because of immunosuppression or surgery.
What client would be most in need of an endotracheal tube?
Comatose client Explanation: Examples include those with respiratory difficulty, comatose clients, those undergoing general anesthesia, and clients with extensive edema of upper airway passages.
Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?
Continuous positive airway pressure (CPAP) Explanation: CPAP is the most effective treatment for OSA because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient must be breathing independently. BiPAP ventilation offers independent control of inspiratory and expiratory pressure while providing pressure support ventilation. Mechanical ventilation is not the most effective treatment for OSA. Administration of low-flow nasal oxygen at night can help relieve hypoxemia in some patients but has little effect on the frequency or severity of apnea.
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? a) Infection b) Post operative bleeding c) Edema of the upper airway d) Plugged tracheostomy tube
Edema of the upper airway Explanation: An endotracheal tube is inserted through the mouth or nose into the trachea to provide a patent airway for clients who cannot maintain an adequate airway on their own. The scenario does not indicate infection, post operative bleeding, or a plugged tracheostomy tube.
A client stops breathing during sleep as a result of repetitive upper airway obstruction. To help decrease the frequency of the apneic episodes, the nurse intervenes by informing the client to:
Eliminate alcohol ingestion. Explanation: The client's symptoms are consistent with obstructive sleep apnea. Initial treatment includes avoidance of alcohol and hypnotic medications. Clients are told to not sleep on their backs. Administration of nasal oxygen may help with hypoxemia but has little effect on the frequency of apnea.
Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require?
Emotional support Explanation: Clients with a malignancy of the larynx require emotional support before and after surgery and help in understanding and choosing an alternative method of speech. It does not require a referral for counseling or vocational training. It also does not require family counseling.
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. Explanation: The nurse should encourage a client undergoing laryngeal surgery to practice deep breathing and coughing every 2 hours while the client is awake. These measures prevent atelectasis and promote effective gas exchange. Monitoring for signs of dysphagia and providing meticulous mouth care every 4 hours are the interventions related to the client's caloric intake.
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 Explanation: For a patient who has undergone surgery for a nasal obstruction, it is important for the nurse to emphasize that nasal packing will be in place postoperatively, necessitating mouth breathing. The nurse applies an ice pack to reduce pain and swelling and not a warm pack. The nurse recommends the use of a splint and the application of pressure to the convex portion of the nose in case of a nasal fracture.
The nurse is caring for a male patient diagnosed with rhinosinusitis. The physician has ordered the patient to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the patient that a common side effect of this medication includes which of the following?
Epistaxis Explanation: Common side effects of budesonide include epistaxis, pharyngitis, cough, nasal irritation, and bronchospasms.
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 Explanation: The signs and symptoms described are consistent with acute pharynigitis. The nurse needs to assess for a fever higher than 39.3°C. Findings will help to determine if the client requires antibiotic therapy. The client may also experience headache, myalgias, and nausea. The nurse needs to assess for these symptoms also, and symptomatic treatment would then be provided.
A 76-year-old man presents to the ED complaining of "laryngitis." The triage nurse should ask if the patient has a past medical history that includes which of the following? a) Congestive heart failure (CHF) b) Respiratory failure (RF) c) Gastroesophageal reflux disease (GERD) d) Chronic obstructive pulmonary disease (COPD)
Gastroesophageal reflux disease (GERD) Explanation: The nurse should ask if the patient has a past medical history of GERD. Laryngitis in the older adults is common and may be secondary to GERD. Older adults are more likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. COPD, CHF, and RF are not associated with laryngitis in the older adult.
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 Explanation: All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis.
A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?
Laryngeal cancer Explanation: Persistent hoarseness (longer than 2 weeks) is usually the earliest symptom.
Which type of sleep apnea is characterized by lack of airflow due to pharyngeal occlusion?
Obstructive Explanation: Obstructive sleep apnea occurs usually in men, and especially in men who are older and overweight. Types of sleep apnea do not include a simple characterization. Mixed sleep apnea is a combination of central and obstructive apnea with one apneic episode. In central sleep apnea, the patient demonstrates simultaneous cessation of both airflow and respiratory movements.
The nurse is caring for a patient admitted with a diagnosis of bacterial pharyngitis. The nurse anticipates the patient will be ordered which of the following medications?
Penicillin Explanation: Treatment of choice for bacterial pharyngitis is penicillin. Penicillin V potassium taken for 5 days is the regimen of choice. Traditionally, penicillin was administered as a single injection; however, oral forms are used more often and are as effective and less painful than injections. Penicillin injections are recommended only if there is a concern that the patient will not comply with therapy. Robitussin DM may be used as an antitussive. For severe sore throats aspirin or Tylenol, or Tylenol with codeine may be given.
A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client:
Sleep with the head of bed elevated. Explanation: General nursing interventions for chronic rhinosinusitis include teaching the client how to provide self-care. These measures include elevating the head of the bed to promote sinus drainage. Caffeinated beverages and alcohol may cause dehydration. Saline irrigations are used to eliminate drainage from the sinuses.
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? a) The client will have decreased pain. b) The client will have decreased edema. c) The client will remain alert and oriented. d) The client will have increased tissue perfusion.
The client will have decreased edema. Explanation: Elevating the head of the bed 45° when the client is fully awake decreases surgical edema and increases lung expansion. At this point in the recovery, elevating the head of the bed will not decrease the surgical pain as pain medication will be needed. Elevating the head of the bed will not affect mentation nor increase the blood supply.
Most cases of acute pharyngitis are caused by which of the following?
Viral infection Explanation: Most cases of acute pharyngitis are caused by viral infection. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus.
A late complication of radiation therapy includes
laryngeal necrosis. Explanation: Late complications of radiation therapy include laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy.
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward. Explanation: Sitting upright and leaning slightly forward avoids increasing vascular pressure in the nose and helps the client avoid aspirating blood. Lying supine won't prevent aspiration of the blood. Nose blowing can dislodge any clotting that has occurred. Bending at the waist increases vascular pressure in the nose and promotes bleeding rather than halting it.
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of
2 to 12 days. Explanation: HSV-1 is transmitted primarily by direct contact with infected secretions. The time period 0 to 3 months exceeds the incubation period. The time period 20 to 30 days exceeds the incubation period. The time period 3 to 6 months exceeds the incubation period.
Which of the following interventions regarding nutrition is implemented for patients who have undergone laryngectomy?
Use enteral feedings after the procedure Explanation: Enteral feedings are used 10 to 14 days after a laryngectomy to avoid irritation to the sutures and reduce the risk of aspiration. When oral intake resumes, the nurse offers small amounts of thick liquids. Following a laryngectomy, the patient may experience anorexia related to a diminished sense of taste and smell. Excess zinc can impair the immune system and lower the levels of high-density lipoproteins ("good" cholesterol). Therefore, long-term or ongoing use of zinc lozenges to prevent a cold is not recommended.
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. Explanation: The carotid artery lies close to the stoma and may rupture from erosion if the wound does not heal properly. Pulmonary embolism is associated with immobility. Dehydration may lead to poor wound healing and breakdown. Pneumonia is a risk for any postoperative patient.
Another term for clergyman's sore throat is
chronic granular pharyngitis. Explanation: In clergyman's sore throat, the pharynx is characterized by numerous swollen lymph follicles. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane.
When caring for a client who has just had a total laryngectomy, the nurse should plan to:
develop an alternative communication method. Explanation: A client with a laryngectomy can't speak, but still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. After a laryngectomy, edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury to the tracheal mucosa, the nurse should deflate the tracheostomy cuff or use the minimal leak technique. To decrease edema, the nurse should place the client in semi-Fowler's position. (l
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." Explanation: Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes.
A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
"Keep the stoma moist." Explanation: The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities.
A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy?
"Tell my wife about it, I do not want to touch it." Explanation: Not wanting to participate in care and diverting the care to others indicates that the client has not accepted the tracheostomy. It is correct to carry tissues with the client because new tracheostomy tubes produce much mucous due to the irritation of the tube in the throat. Consideration need to be arranged by being in a swimming pool may be completed as long as water does not surround the new tracheostomy. Stating the reality of not being able to remove the tracheostomy provides data that the client is accepting the tracheostomy as part of life.
The nurse is discussing immediate postoperative communication strategies with a patient scheduled for a total laryngectomy. Which of the following information will the nurse include?
"You can use writing or a communication board to communicate." Explanation: If a total laryngectomy is scheduled, the patient must understand that the natural voice will be lost, but that special training can provide a means for communicating. The patient needs to know that until training is started, communication will be possible by using the call light, by writing, or by using a special communication board. The use of an electronic device is a long-term postoperative goal. The speech therapist will evaluate the patient prior to surgery and a method of immediate postoperative communication will be established.
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?
A face mask Explanation: A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device.
A 72-year-old male client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. If laryngeal cancer is suspected, the nurse would be most likely to hear which of the following complaints from the client?
A feeling of swelling at the back of the throat Explanation: After an initial hoarseness lasting longer than a month, clients with laryngeal cancer will feel a sensation of swelling or a lump in the throat or in the neck. Weight loss often occurs later in the progression of laryngeal cancer due to reduced calorie intake as a result of impaired swallowing and pain. Clients with laryngeal cancer may complain of burning in the throat when swallowing hot or citrus liquids. Clients with obstructive sleep apnea may experience a morning headache.
You are caring for a client who has just been told they have advanced laryngeal cancer and will have to have a total laryngectomy. You are doing preoperative teaching with this client. What do you know is a subject you should cover?
Alternative methods of communication Explanation: Discuss alternative methods of communication and identify which method the client prefers. Visiting hours, pain and post operative nutrition are not generally covered at this point in preoperative teaching.
The nurse assesses a patient who is bleeding profusely from the nose. The nurse documents this finding as which of the following conditions?
Epistaxis Explanation: Epistaxis is due to rupture of tiny, distended vessels in the mucous membrane of any area of the nose. Xerostomia refers to dryness of the mouth. Rhinorrhea refers to drainage of a large amount of fluid from the nose. Dysphagia refers to difficulties in swallowing.
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. Explanation: Postoperatively, the patient may not be permitted to eat or drink for at least 7 days. Alternative sources of nutrition and hydration include IV fluids, enteral feedings through a nasogastric or gastrostomy tube, and parenteral nutrition. Once the patient is permitted to resume oral feedings, thin liquids are offered, and sweet food are avoided because they cause increased salivation and decrease the patient's appetite. The patient's taste sensations are altered for a while after surgery because inhaled air passes directly into the trachea, bypassing the nose and the olfactory end organs. In time, however, the patient usually accommodates to this change and olfactory sensation adapts; thus, seasonings are based on personal preferences.
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 Explanation: Later, the client notes a sensation of swelling or a lump in the throat, followed by dysphagia and pain when talking. Hoarseness is not indicative of pharyngeal cancer; laryngeal polyps; or cancer of the tonsils.
You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
Noisy breathing Explanation: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following a tracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.
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 Explanation: Potential complications of acute bacterial rhinosinusitis are nuchal rigidity and severe headache. Hypertension may be a result of over-the-counter decongestant medications. Nausea may be a result of nasal corticosteroids.
Which of the following medications is the treatment of choice for bacterial pharyngitis?
Penicillin Explanation: Treatment of choice for bacterial pharyngitis is penicillin. Robitussin DM may be used as an antitussive. For severe sore throats aspirin or Tylenol, or Tylenol with codeine may be given.
The nurse is assessing a patient in the clinic, and upon physical assessment the patient demonstrates displacement of the sternum. This would be documented as which of the following conditions?
Pigeon chest Explanation: Pigeon chest may occur with rickets, Marfan's syndrome, or severe kyphoscoliosis. A barrel chest is seen in patients with emphysema and occurs as a result of over-inflation of the lungs. A funnel chest occurs when there is a depression in the lower portion of the sternum. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine.
A young adult client has had a tonsillectomy and is in the immediate postoperative period. To make the client comfortable, the nurse intervenes by
Placing the client prone with the head turned to the side Explanation: The most comfortable position for the client in the immediate postoperative period is prone, not semi-Fowler's. The client's head is turned to the side to allow drainage from the mouth. The oral airway is removed after the gag reflex has returned. An ice collar, not warm compress, is applied to the neck area.
A patient presents to the ED with a suspected allergic reaction. The patient is experiencing laryngeal edema causing obstruction and is demonstrating retractions in the neck during inspirations. Which of the following is the nurse's priority intervention?
Prepare to administer subcutaneous epinephrine and corticosteroids. Explanation: The use of accessory muscles to maximize airflow is often manifested by retractions in the neck during inspirations and is an ominous sign of impending respiratory distress. The patient's obstruction is caused by edema resulting from an allergic reaction, and treatment should include immediate administration of subcutaneous epinephrine and a corticosteroid. The other interventions may be indicated for a patient with a laryngeal obstruction; however, in this instance the most appropriate intervention to treat the patient's laryngeal edema is the administration of the medications
Your client is status post total laryngectomy and cannot talk. What intervention should you make to help this client communicate?
Provide alternative methods of communication. Explanation: Provide alternative methods of communication: paper and pen, wipe board, or word or picture board. Having supplies available provides comfort to client. A client who is post total laryngectomy would have learned about esophageal speech and an artificial larynx prior to surgery. You would not provide a lip reader as a translator.
A client has a nursing diagnosis of acute pain related to upper airway irritation. The best short-term goal for this client is for the client to
Report relief of pain to level 3 using a pain intensity scale of 1 to 10. Explanation: The client statement of relief of pain to level 3 indicates improvement of the problem. The other options are actually interventions or actions that can help achieve a long-term goal of relief of pain.
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 Explanation: The client should seek medical assistance if swallowing is impaired to prevent aspiration. Following Maslow's hierarchy of needs, airway clearance is the highest priority.
Which of the following diagnostic tests is used to confirm the diagnosis of maxillary and frontal sinusitis?
Sinus aspirates Explanation: To confirm the diagnosis of maxillary and frontal sinusitis and identify the pathogen, sinus aspirates may be obtained. Flexible endoscopic culture techniques and swabbing of the sinuses have been used for this purpose. Sinus x-rays and CT scans may be obtained for patients with frontal headaches, in refractory cases, and if complications are suspected.
The nurse is providing discharge instructions for a patient following laryngeal surgery. The nurse instructs the patient to avoid which of the following?
Swimming Explanation: Swimming is not recommended because a person with a laryngectomy can drown without submerging his or her face. Special precautions are needed in the shower to prevent water from entering the stoma. Wearing a loose-fitting plastic bib over the tracheostomy or simply holding a hand over the opening is effective. The nurse also suggests that the patient wear a scarf over the stoma to make the opening less obvious. The nurse encourages the patient to cough every 2 hours to promote effective gas exchange
Which of the following postoperative instructions does a nurse provide a patient and family to avoid after a laryngeal surgery?
Swimming Explanation: The nurse provides the patient and family with the following postoperative instructions:water should not enter the stoma because it will flow from the trachea to the lungs. Therefore, the nurse instructs the patient to avoid swimming and to use a hand-held shower device when bathing. The nurse also suggests that the patient to wear a scarf over the stoma to make the opening less obvious. The nurse encourages the patient to cough every 2 hours to promote effective gas exchange.
Stiffness of the neck or inability to bend the neck is referred to as
nuchal rigidity. Explanation: Nuchal rigidity is the stiffness of the neck or inability to bend the neck. Aphonia is impaired ability to use one's voice due to distress or injury to the larynx. Xerostomia is the dryness of the mouth from a variety of causes. Dysphagia is difficulty swallowing.
A nurse is teaching a client with recurrent rhinosinusitis and instructs the client to take the following medication at the first sign of symptoms:
guaifenesin (Mucinex) Explanation: The client should take a decongestant (eg, guaifenesin) at the first sign of recurrence of rhinosinusitis to promote drainage of the sinus cavities and prevent bacterial infection. Medications that the client may take later in the illness for pain relief include acetaminophen and nonsteroidal antinflammatory drugs, such as naproxen. Over-the-counter nasal sprays (eg, Afrin) may cause rebound congestion.
A patient is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include
hoarseness. Explanation: Signs of acute laryngitis include hoarseness or aphonia and severe cough. Other signs of acute laryngitis include a dry cough, and a throat that feels worse in the morning. If allergies are present, the uvula will be visibly edematous
The client is postoperative immediately following a total laryngectomy. The client's respirations are 32 breaths/minute, shallow, and noisy. The tracheostomy pad is moist. Pulse oximetry is 88%. The client's eyes are wide open, and the client appears apprehensive. The client is receiving humidified oxygen. A priority nursing
ineffective airway clearance related to excess mucus production Explanation: All may be appropriate nursing diagnoses for this client. The nurse would follow Maslow's hierarchy of needs and ABCs (airway, breathing, circulation) to determine highest priority. Ineffective airway clearance is the nursing diagnosis of highest priority.
Which of the following are clinical manifestations associated with obstructive sleep apnea (OSA)? Select all that apply.
• Insomnia • Arrhythmias • Loud snoring • Excessive daytime sleepiness • Impotence Explanation: Clinical manifestations associated with OSA include excessive daytime sleepiness, insomnia, loud snoring, impotence, and arrhythmias.
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 his 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 Explanation: An endotracheal tube is inserted through the mouth or nose into the trachea to provide a patent airway for clients who cannot maintain an adequate airway on their own. The scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy tube.
The nurse is instructing a client who is scheduled for a laryngectomy about methods of alaryngeal speech. Which of the following best describes tracheoesophageal puncture (TEP)?
It requires the insertion of a prosthesis into the trachea. Explanation: TEP requires a surgical opening in the posterior wall of the trachea, followed by the insertion of a prosthesis such as a Blom-Singer device. An artificial larynx is a throat vibrator held against the neck that projects sound into the mouth. With esophageal speech, the client forms words with the lips. Esophageal speech causes the voice quality to be lower pitched and gruff sounding.
The nurse is caring for a patient receiving radiation therapy for laryngeal cancer. A late complication of radiation therapy includes which of the following?
Laryngeal necrosis Explanation: Late complications of radiation therapy include laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy.
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." Explanation: Commonly, family members are reluctant to talk to the client who has had a total laryngectomy and can no longer speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing.
