CH9 Nursing Management: Patients with Upper Respiratory Tract Disorders

Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy? impaired verbal communication deficient knowledge risk for infection risk for chronic low self-esteem

impaired verbal communication Explanation: Loss of the ability to speak normally is a devastating consequence of laryngeal surgery and is certain with a total laryngectomy. Issues with self-esteem and deficient knowledge are possible, but less certain. Infection is a risk, but not a certainty. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 278.

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? Infection Post operative bleeding Edema of the upper airway 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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 282.

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? Infection Postoperative bleeding Edema of the upper airway Plugged tracheostomy tube

Edema of the upper airway Explanation: With severe respiratory distress in a status post adenoidectomy client, the nurse would suspect an airway issue related to edema of the upper airway. The scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy tube. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019.

Wound drains, inserted during the laryngectomy, stay in place until what criteria are met? The stoma is healed, about 6 weeks after surgery. The surgical site is dry with encrustations. Drainage is <30 mL/day for 2 consecutive days. The patient is able to assist with his own suctioning.

Drainage is <30 mL/day for 2 consecutive days. Explanation: Drains are removed when secretions are minimal, which usually is less than 30 mL for 48 straight hours. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 279.

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." "It is fine to speak in a whisper. This does not strain your voice." "Do not use a humidifier; it will make your problem worse." "The 'tickle' in your throat will improve with cold liquids."

"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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 265.

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?" "Have you strained your voice recently?" "Do you eat a lot of red meat?" "Do you eat spicy foods?"

"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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 274.

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? "Clean the tracheostomy tube with alcohol and water." "Family members should continue to talk to the client." "Oral intake of fluids should be limited for 1 week only." "Limit the amount of protein in the diet."

"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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 276.

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says: "I need to keep my inhaler at the bedside." "I should eat a high-protein diet." "I should become involved in a weight loss program." "I should sleep on my side all night long."

"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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 269.

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? "I have environmental allergies." "I smoke a pack of cigarettes a day." "I used my voice in excess over the weekend." "I was chewing ice chips all day long."

"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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 274.

The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include? "After surgery you will have a sore throat, but you will be able to speak." "You can use writing or a communication board to communicate." "After surgery you will have to use an electric larynx to communicate." "A speech therapist will evaluate you and recommend a system of communication after surgery."

"You can use writing or a communication board to communicate." Explanation: If a total laryngectomy is scheduled, the client must understand that the natural voice will be lost but special training can provide a means for communicating. The client needs to know that until training is started, communication will be possible using the call light, through writing, or using a special communication board. The use of an electronic device is a long-term postoperative goal. The speech therapist will evaluate the client before surgery and establish a method of immediate postoperative communication. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Promoting Alternative Communication Methods, p. 279.

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of 2 to 12 days. 20 to 30 days. 1 to 3 months. 3 to 6 months.

2 to 12 days. Explanation: HSV-1 is transmitted primarily by direct contact with infected secretions. The time periods of 20 to 30 days, 1 to 3 months, and 3 to 6 months exceed the incubation period. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Clinical Manifestations and Assessment, p. 262.

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? Apply an ice pack. Restrict fluid intake. Position the patient in the side-lying position. Apply pressure to the convex of the nose.

A pack.apply an ice Explanation: Following a nasal fracture, the nurse applies ice and encourages the client to keep the head elevated. The nurse instructs the client 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 client 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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Nursing Management, p. 273.

A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: One vocal cord was removed along with a portion of the larynx. The voice was spared and a tracheostomy would be in place until the airway was established. A permanent tracheal stoma would be necessary. A portion of the vocal cord was removed

A permanent tracheal stoma would be necessary. Explanation: A total laryngectomy will result in a permanent stoma and total loss of voice. A partial laryngectomy involves the removal of one vocal cord. The voice is spared with the supraglottic laryngectomy. Removal of a portion of the vocal cord occurs with a hemilaryngectomy. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 276.

A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: One vocal cord was removed along with a portion of the larynx. The voice was spared and a tracheostomy would be in place until the airway was established. A permanent tracheal stoma would be necessary. A portion of the vocal cord was removed.

A permanent tracheal stoma would be necessary. Explanation: A total laryngectomy will result in a permanent stoma and total loss of voice. A partial laryngectomy involves the removal of one vocal cord. The voice is spared with the supraglottic laryngectomy. Removal of a portion of the vocal cord occurs with a hemilaryngectomy. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 276.

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 An antibiotic such as amoxicillin An antihistamine such as Benadryl An ointment such as bacitracin

An antiviral agent such as acyclovir Explanation: Herpes labialis is an infection that is caused by herpes simplex virus type 1 (HSV-1). It is characterized by an eruption of small, painful blisters on the skin of the lips, mouth, gums, tongue, or the skin around the mouth. The blisters are commonly referred to as cold sores or fever blisters. Medications used in the management of herpes labialis include acyclovir (Zovirax) and valacyclovir (Valtrex), which help to minimize the symptoms and the duration or length of flare-up. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Medical and Nursing Management, pp. 262-263.

A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis? Apply a moustache dressing. Provide a nasal splint. Apply direct continuous pressure. Place the client in a semi-Fowler's position.

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, pp. 270-271.

A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis? Apply a moustache dressing. Provide a nasal splint. Apply direct continuous pressure. Place the client in a semi-Fowler's position.

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, pp. 270-271.

A 13-year-old boy has been brought to the emergency department by his mother after he took a powerful blow to his nose during a volleyball game. Preliminary examination suggests a nasal fracture, which should prompt the nurse to: Apply ice and tell the patient to keep his head elevated Administer saline lavage and tell the patient not to swallow the solution Apply warm compresses to the bridge of the patient's nose Administer analgesia and a nebulized bronchodilator

Apply ice and tell the patient to keep his head elevated Explanation: Immediately after the fracture, the nurse applies ice and encourages the patient to keep the head elevated. Saline lavage, warm compresses, and nebulizers are not common treatment modalities for nasal fractures. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Nursing Management, p. 273.

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? Preparing the patient for a septoplasty Applying nasal packing Administering nasal lavage Applying steroidal nasal spray

Applying nasal packing Explanation: A nasal fracture very often produces bleeding from the nasal passage. As a rule, bleeding is controlled with the use of packing. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 272.

The nurse is preparing to suction a patient with an endotracheal tube. What would be the nurse's first step in the suctioning process? Explain the procedure to the patient before beginning and offer reassurance during suctioning. Turn on suction source at or below 120 mm Hg. Assess the patient's lung sounds and SaO2 via pulse oximeter. Perform hand hygiene, then put on nonsterile gloves, goggles, gown, and mask.

Assess the patient's lung sounds and SaO2 via pulse oximeter. Explanation: Assessment data indicate the need for suctioning and allow the nurse to monitor the effects of suctioning on the patient's level of oxygenation. Explaining the procedure would be the second step; performing hand hygiene is the third step, and turning on the suction source is the fourth step. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Suctioning the Tracheal Tube (Tracheostomy or Endotracheal Tube), p. 286.

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? Obtain vital signs. Monitor heart rhythm. Auscultate lung sounds. Assess capillary refill.

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 284.

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? Avoid sports activities for 6 weeks. Decrease the amount of daily fluids. Take aspirin for nasal discomfort. Administer normal saline nasal drops as ordered.

Avoid sports activities for 6 weeks. Explanation: The nurse instructs the client to avoid sports activities for 6 weeks. There is no indication for the client 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 client should take analgesic agents, such as acetaminophen or NSAIDs (i.e., ibuprofen or naproxen), to decrease nasal discomfort, not aspirin. The client does not need to use nasal drops when nasal packing is in place. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 273.

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately? Bleeding Difficulty swallowing Throat pain Difficulty talking

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019.

The health care provider has ordered continuous positive airway pressure (CPAP) with the delivery of oxygenation. The patient asks the nurse what the benefit of CPAP is. What would be the nurse's best response? CPAP allows a higher percentage of oxygen to be used CPAP prevents the collapse of the patient's airway CPAP eliminates the need for oxygen supplementation during the day CPAP alters alveolar perfusion

CPAP prevents the collapse of the patient's airway Explanation: CPAP provides positive pressure to the airways throughout the respiratory cycle preventing collapse. It does not eliminate the need for supplementary oxygen or alter perfusion. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Box 9-2, p. 271.

Which assessment finding puts a client at increased risk for epistaxis? Use of a humidifier at night Hypotension Cocaine use History of nasal surgery

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 272.

What client would be most in need of an endotracheal tube? A client status post tonsillectomy Ambulatory clients Older adult clients Comatose clients

Comatose clients Explanation: Examples include those with respiratory difficulty, comatose clients, those undergoing general anesthesia, and clients with extensive edema of upper airway passages. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 282.

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. Encourage oral nutrition on the second postoperative day. Maintain the client in a low-Fowler's position. Assess the tracheostomy cuff for le

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, pp. 278-279.

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. Encourage oral nutrition on the second postoperative day. Maintain the client in a low-Fowler's position. Assess the tracheostomy cuff for leaks.

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, pp. 278-279.

Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require? Emotional support Referral for counseling Family counseling Referral for vocational training

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 268.

You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis? Monitor for signs of dysphagia. Provide meticulous mouth care every 4 hours. Caution against frequent coughing. Encourage deep breathing every 2 hours.

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Maintaining a Patent Airway, p. 278.

A 60-year-old man has been diagnosed with obstructive sleep apnea (OSA) based on his clinical symptoms and polysomnographic findings. What intervention should the nurse perform to assist this patient in the management of his health problem? Encouraging the patient to adopt a later bedtime and earlier rising hour Encouraging the patient to avoid alcohol and hypnotic medications Teaching the patient deep breathing and coughing exercises to perform before going to bed Teaching the patient strategies for waking himself up when he experiences an apneic spell

Encouraging the patient to avoid alcohol and hypnotic medications Explanation: Treatments for OSA are varied but include weight loss and avoidance of alcohol and hypnotic medications initially. Patients are not normally able to awaken themselves during apneic periods. Deep breathing exercises and changes to sleeping times are not known to improve the signs and symptoms of OSA. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Medical Management, p. 269.

Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction? Apply a warm pack postoperatively Ensure mouth breathing Apply pressure to the convex portion of the nose Provide a splint postoperatively

Ensure mouth breathing Explanation: For a client 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 breathing through the mouth. 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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Nursing Management, p. 272.

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 Headache Myalgias Nausea

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Clinical Manifestations and Assessment, pp. 265-266.

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? Gram-negative Klebsiella Pseudomonas aeruginosa Group A, beta-hemolytic streptococcus Staphylococcus aureus

Group A, beta-hemolytic streptococcus Explanation: The adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. Infection of the adenoids frequently accompanies acute tonsillitis. Frequently occurring bacterial pathogens include group A, beta-hemolytic streptococcus, the most common organism. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 265.

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. Hoarseness of more than 2 week's duration Dysphasia Persistent ulceration Cervical lymph adenopathy

Hoarseness of more than 2 week's duration Explanation: Hoarseness of more than 2 weeks' duration occurs in the patient with cancer in the glottic area, because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh, raspy, and lower in pitch. Later symptoms include dysphasia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath. Cervical lymph adenopathy, unintentional weight loss, a general debilitated state, and pain radiating to the ear may occur with metastasis. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 274.

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 Acute pain related to upper airway irritation Deficient fluid volume related to increased fluid needs Deficient knowledge related to prevention of upper respiratory infections Ineffective airway clearance related to excess mucus production

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 267.

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 Acute pain related to upper airway irritation secondary to an infection Deficient fluid volume related to decreased fluid intake and increased fluid loss secondary to diaphoresis associated with a fever Deficient knowledge regarding prevention of upper airway infections, treatment regimens, the surgical procedure, or postoperative care

Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation Explanation: Ineffective airway clearance can lead to respiratory depression, which necessitates immediate intervention. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 267.

The nurse is preparing the care plan for a patient who is scheduled for a laryngectomy. Which nursing diagnosis should receive the highest priority? Anxiety related to diagnosis of cancer Altered nutrition related to swallowing difficulties Ineffective airway clearance related to surgical alterations in the airway Impaired verbal communication related to removal of the larynx

Ineffective airway clearance related to surgical alterations in the airway Explanation: Each of the listed diagnoses is a valid nursing diagnosis, but ineffective airway clearance is the priority nursing diagnosis for all conditions. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Surgical Management, p. 276.

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? Initiate enteral feedings. Offer plenty of thin liquids. Encourage sweet foods. Liberally season foods.

Initiate enteral feedings. Explanation: Postoperatively, the client 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 client is permitted to resume oral feedings, thick liquids are offered; sweet foods are avoided because they cause increased salivation and decrease the client's appetite. The client'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 client usually accommodates to this change and olfactory sensation adapts; thus, seasoning is based on personal preferences. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Promoting Adequate Nutrition and Hydration, p. 279.

A patient with a diagnosis of acute rhinosinusitis has approached the nurse and asked for advice about "rinsing out my sinuses with saltwater," a treatment that was suggested by a friend. The nurse's response should be premised on which of the following statements? Saline rinses have the potential to damage the mucosa of the sinuses. Nasal saline lavage can help to improve the patency of the sinuses. Nasal saline lavage can result in rebound congestion. Rinsing with saline has been shown to be ineffective in clearing the sinuses of mucus.

Nasal saline lavage can help to improve the patency of the sinuses. Explanation: Nasal saline lavage can improve patency of the ostiomeatal unit (area where the frontal and maxillary sinuses normally drain into the nasal cavity) and improve drainage of the sinuses. This practice is considered safe and does not produce the rebound congestion associated with topical decongestants. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Medical and Nursing Management, p. 265.

The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? Incrusted mucous membranes Hardened secretions Erosion of the trachea Noisy breathing

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 264.

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? Total laryngectomy Cordectomy Vocal cord stripping Partial laryngectomy

Partial laryngectomy Explanation: A partial laryngectomy (laryngofissure-thyrotomy) is often used for patients in the early stages of cancer in the glottis area when only one vocal cord is involved. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 276.

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 Supraglottic laryngectomy Hemilaryngectomy Total laryngectomy

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 276.

During a period of significant workplace stress, a patient has been experiencing the recurrence of viral rhinitis for the past several weeks and claims that he has been unable to fully recover from this cold. The nurse should recognize that this patient is at risk of developing: Epistaxis Rhinosinusitis Epiglottitis Allergic rhinitis

Rhinosinusitis Explanation: Acute rhinosinusitis usually follows a viral upper respiratory infection (URI) or cold, such as an unresolved viral or bacterial infection, or an exacerbation of allergic rhinitis. Epistaxis, epiglottitis, and allergic rhinitis are not typical complications of a prolonged cold. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Pathophysiology, p. 264.

A client is experiencing acute viral rhinosinusitis. The nurse is providing instructions about self-care activities and includes information about Cold compresses to the sinus cavities Use of a dehumidifier Saline lavages to the nares Administration of oral antibiotics

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Medical and Nursing Management, p. 265.

A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to Stay in bed when experiencing a fever Properly dispose of used tissues Seek medical help if he experiences inability to swallow Place an ice collar on the throat to relieve soreness

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 266.

A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client: Sleep with the head of bed elevated. Caffeinated beverages are allowed. You may drink 1 glass of alcohol daily. Do not perform saline irrigations to the nares.

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 265.

Bacterial infection occurs in about 70% of those who have acute rhinosinusitis. The nurse is aware that the least common bacteria is: Streptococcus pneumonia Haemophilus influenza Staphylococcus aureus Moraxella catarrhalis

Staphylococcus aureus Explanation: Staphylococcus aureus is the least common infecting organism. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019.

When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided? Hand-held showers Wearing a scarf over the stoma Swimming Coughing

Swimming Explanation: The nurse provides the client 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 client to avoid swimming and to use a handheld shower device when bathing. The nurse also suggests that the client wear a scarf over the stoma to make the opening less obvious. The nurse encourages the client to cough every 2 hours to promote effective gas exchange. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 281.

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 Pinching the upper and hard portion of the nose Instructing the client to tilt the head back with ice applied to the nose Applying pressure to the nose for 1 to 2 minutes

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 272.

A female patient with obstructive sleep apnea (OSA) has been recommended a continuous positive airway pressure (CPAP) machine for the treatment of her health problem. The nurse's priority for patient education should be: The need to use inhaled corticosteroids and bronchodilators each night prior to applying CPAP The importance of participating in daily physical exercise when using CPAP on a regular basis The need to have continuous pulse oximetry in place while the CPAP machine is in use The importance of complying with CPAP despite the inconvenience associated with its use

The importance of complying with CPAP despite the inconvenience associated with its use Explanation: Although CPAP is effective in management of OSA, patient compliance with the treatment continues to be a major concern. Nursing interventions aimed at increasing compliance are consequently a priority. Steroids, bronchodilators, and pulse oximetry are not normally necessary. Daily exercise is beneficial but the promotion of compliance is a priority for patients using CPAP. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Box 9-2, p. 271.

The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice? Partial laryngectomy Laser surgery Radiation therapy Total laryngectomy

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Surgical Management, p. 276.

The nurse in a long-term-care facility is aware of the importance of preventing upper respiratory infections (URIs) among the residents of the facility. How is this best accomplished? Vigilant handwashing by staff and residents Providing a high-calorie diet for residents Encouraging residents' fluid intake Providing topical decongestants to residents

Vigilant handwashing by staff and residents Explanation: Thorough handwashing is the mainstay of URI prevention. Nutritious diet, high fluid intake, and the use of decongestants may be necessary treatments for residents who have URIs, but none of these measures appreciably protects against the development of URIs. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Evaluation, p. 268.

The nurse is performing patient teaching with a young mother who has brought her 3-month-old to the clinic for a well-baby check. Knowing that it is cold season, what information should the nurse provide to the mother to best prevent transmission of organisms? Take prescribed antibiotics Use warm salt-water gargles Dress warmly Wash hands frequently

Wash hands frequently Explanation: Hand washing remains the most effective preventive measure to reduce the transmission of organisms. Taking prescribed antibiotics, using warm salt-water gargles, and dressing warmly does not suppress transmission. Antibiotics are not prescribed for a cold. Warm, salt-water gargles do not prevent the transmission of organisms, nor does dressing warmly. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Box 9-8, p. 286.

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 When the patient states that there is discomfort and requests removal When the drainage tube comes out In 1 week when the patient no longer has serous drainage

When the patient has less than 30 mL for 2 consecutive days Explanation: Wound drains, inserted during surgery, may be in place to assist in removal of fluid and air from the surgical site. Suction also may be used, but cautiously, to avoid trauma to the surgical site and incision. The nurse observes, measures, and records drainage. When drainage is less than 30 mL/day for 2 consecutive days, the physician usually removes the drains. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 279.

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? a feeling of swelling at the back of the throat weight loss discomfort when drinking cold liquids headaches in the morning

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 report burning in the throat when swallowing hot or citrus liquids. Clients with obstructive sleep apnea may experience a morning headache. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, p. 264.

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 Places both arms around the worker's waist Makes a fist with one hand with the thumb outside the fist Exerts pressure against the worker's abdomen

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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders, Box 9-5, p. 275.