Chapter 18 Management of Patients with Upper Respiratory Tract Disorders PrepU

A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client? "Gargle with a warm salt solution." "You may have a sore throat for 1 week." "You are allowed to have hot tea or coffee." "Decrease oral intake if increased swallowing occurs."

"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.

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.

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.

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.

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 Wait 10 seconds before administering the second spray. Tilt the head back when activating the spray of the medication. Clean the medication container once each day. Blow the nose before applying medication into the nares.

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.

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.

The nurse is caring for a client diagnosed with rhinosinusitis. The physician has ordered the client to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the client that a common side effect of this medication is Headache Epistaxis Arthralgia Watery eyes

Epistaxis Explanation: Common side effects of budesonide (Rhinocort) include epistaxis, pharyngitis, cough, nasal irritation, and bronchospasm.

A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes Gastroesophageal reflux disease (GERD) Chronic obstructive pulmonary disease (COPD) Congestive heart failure (CHF) Respiratory failure (RF)

Gastroesophageal reflux disease (GERD) Explanation: The nurse should ask whether the client has a medical history of GERD. Laryngitis is common in older adults 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 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.

Which is the priority nursing diagnosis for a client undergoing a laryngectomy? Imbalanced nutrition: Less than body requirements Impaired verbal communication Ineffective airway clearance Anxiety and depression

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 the question is asking for the priority nursing diagnosis for this patient. The priority is to identify any issues related to impaired airway.

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.

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? Cancer of the pharynx Laryngeal cancer Laryngeal polyps Cancer of the tonsils

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.

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.

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.

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.

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

Staphylococcus aureus Explanation: Staphylococcus aureus is the least common infecting organism.

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.

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? CBC with differential Transillumination of the sinus Nasal culture Magnetic resonance imaging (MRI)

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.

Most cases of acute pharyngitis are caused by which of the following? Viral infection Bacterial infection Fungal infection Systemic infection

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.

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.

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: lie supine with his neck extended. sit upright, leaning slightly forward. blow his nose and then put lateral pressure on his nose. hold his nose while bending forward at the waist.

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.

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 aerosol 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 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.

A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube? "The ET tube will maintain your airway while you're under anesthesia." "The ET tube will be inserted through an opening in your trachea." "The ET tube will remain in place for at least a day postsurgery." "The ET tube will be connected to a negative-pressure ventilator."

"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 who are comatose.

An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by periods of breathing cessation for: 4 seconds with 2 episodes/hour. 6 seconds with 3 episodes/hour. 8 seconds with 4 episodes/hour. 10 seconds with 5 episodes/hour.

10 seconds with 5 episodes/hour. Explanation: OSA is characterized by frequent and loud snoring, with breathing cessation for 10 seconds or longer, for at least five episodes per hour, followed by abrupt awakening with a loud snort as the blood oxygen level drops. Symptoms typically progress with weight gain, aging, and during the transition to menopause for women.

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub? No fluid is normally present 20 mL or less 20-40 mL More than 40 mL

20 mL or less Explanation: The pleural space, located between the visceral and parietal pleura, normally contains 20 mL of fluid or less. The fluid helps lubricate the visceral and parietal pleura.

The nurse assesses a client who has a nasogastric tube for long-term nutritional needs for complications associated with the medical device. Complete the following sentence by choosing from the lists of options. The nurse monitors the client for (Pick one of the First 3 options down below), a finding indicative of (Choose one of the second 3 options down below), a noted complication of nasogastric tubes. purulent nasal drainage polyphagia muscle weakness rhinosinusitis viral pneumonia bacterial pharyngitis

A) Purulent nasal drainage B) Rhinosinusitis Clients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Purulent nasal drainage is a symptom the nurse monitors for when assessing for complications associated with a nasogastric tube. Clients who require nasogastric tube feedings are at risk for rhinosinusitis; thus, the nurse monitors the client for purulent nasal drainage. Polyphagia and muscle weakness are not symptoms indicative of a complication related to the client's nasogastric tube. Aspiration, not viral pneumonia, is a complication associated with nasogastric tube feedings. Although a nasogastric tube can irritate the client's throat, bacterial pharyngitis is not a complication that is associated with this form of nutrition administration.

The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently? Airway patency Level of consciousness Psychological status Pain level

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 priorities are always airway, breathing, and then circulation.

Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)? Amoxicillin Levofloxacin Keflex Ceftin

Amoxicillin Explanation: Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid is the antibiotic of choice. For clients who are allergic to penicillin, doxycycline or respiratory quinolones, such as levofloxacin or moxifloxacin, can be used. Other antibiotics previously prescribed to treat ABRS, including cephalosporins such as cephalexin and cefuroxime, are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.

A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about? Amoxicillin-clavulanic acid Cephalexin Cefuroxime Clarithromycin

Amoxicillin-clavulanic acid Explanation: Treatment of acute rhinosinusitis depends on the cause; a 5- to 7-day course of antibiotics is prescribed for bacterial cases. Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid ( Augmentin) is the antibiotic of choice. Other antibiotics prescribed previously to treat ABRS, including cephalosporins such as cephalexin (Keflex), cefuroxime (Ceftin), cefaclor (Ceclor), and cefixime (Suprax), trimethoprim-sulfamethoxazole (Bactrim, Septra), and macrolides such as clarithromycin (Biaxin) and azithromycin (Zithromax), are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.

The nurse is educating the patient diagnosed with acute pharyngitis on methods to alleviate discomfort. What interventions should the nurse include in the information? (Select all that apply.) Apply an ice collar. Stay on bed rest during the febrile stage of the illness. Gargle with an alcohol-based mouthwash. Try a liquid or soft diet during the acute stage of the disease. Drink warm or hot liquids during the acute stage of the disease.

Apply an ice collar. Stay on bed rest during the febrile stage of the illness. Try a liquid or soft diet during the acute stage of the disease. Explanation: A liquid or soft diet is provided during the acute stage of the disease, depending on the patient's appetite and the degree of discomfort that occurs with swallowing. Cool beverages, warm liquids, and flavored frozen desserts such as ice pops are often soothing. The nurse instructs the patient to stay in bed during the febrile stage of illness and to rest frequently once up and about. Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. An ice collar also can relieve severe sore throats.

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.

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.

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 Apply an ice pack to the nose. Reassure the client that the nose is not fractured. Administer prescribed oral ibuprofen (Motrin). Check the clear fluid for glucose.

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 cribriform 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 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 (There's an image on this question stating the following): Client A Who is HIV positive and 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

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.

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.

A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis? Group A, beta-hemolytic streptococci Gram-negative Klebsiella Pseudomonas aeruginosa Staphylococcus aureus

Group A, beta-hemolytic streptococci Explanation: Viral infection causes most cases of acute pharyngitis. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus. Bacterial infection accounts for the remainder of cases. Ten percent of adults with pharyngitis have group A beta-hemolytic streptococcus (GABHS), which is commonly referred to as group A streptococcus (GAS) or streptococcal pharyngitis.

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? Epistaxis, twice last week Aphonia following a football game Hoarseness for 2 weeks Laryngitis following a cold

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.

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events? Pulmonary hypotension Hypercapnia Systemic hypotension Increased smooth muscle contractility

Hypercapnia Explanation: Repetitive apneic events result in hypoxia and hypercapnia, which triggers a sympathetic response (increased heart rate and decreased tone and contractility of smooth muscle).

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.

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.

A patient comes to the clinic with a cold and wants something to help relieve the symptoms. What should the nurse include in educating the patient about the uncomplicated common cold? (Select all that apply.) Tell the patient to take prescribed antibiotics to decrease the severity of symptoms. Inform the patient about the symptoms of secondary infection. Suggest that the patient take adequate fluids and get plenty of rest. Inform the patient that the virus is contagious for 2 days before symptoms appear and during the first part of the symptomatic phase. Inform the patient that taking an antihistamine will help to decrease the duration of the cold.

Inform the patient about the symptoms of secondary infection. Suggest that the patient take adequate fluids and get plenty of rest. Inform the patient that the virus is contagious for 2 days before symptoms appear and during the first part of the symptomatic phase. Explanation: Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. Management consists of symptomatic therapy that includes adequate fluid intake, rest, prevention of chilling, and the use of expectorants as needed. The nurse instructs the patient about methods to treat symptoms of the common cold and provides both verbal and written information to assist in the prevention and management of URIs.

The nurse makes the observations shown in the accompanying notes about a client who will be discharged following a laryngectomy. The nurse makes a referral to the home health nurse for client reteaching based on which observation? Use of non-sterile tissues to wipe secretions from the airway. Client use of tweezers to remove encrustations. Initial washing of hands after cleaning inner cannula. Wearing a loose-fitting cloth over the stoma.

Initial washing of hands after cleaning inner cannula. Explanation: The client should wash the hands before any care of the surgical site, particularly cleansing of the inner cannula. The other activities are appropriate outcomes for a client following laryngectomy.

The nurse is instructing a client who is scheduled for a laryngectomy about methods of laryngeal speech. Which best describes tracheoesophageal puncture (TEP)? It requires the insertion of a prosthesis into the trachea. It requires the client to hold a throat vibrator against the neck. It enables the client to form words with the lips. It will result in a low, gruff-sounding voice.

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.

A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect? Laryngeal cancer Laryngeal polyps Chronic pharyngitis Chronic tonsillitis

Laryngeal cancer Explanation: Persistent hoarseness (longer than 2 weeks) is usually the earliest symptom.

The nurse is performing preoperative teaching with a client who has cancer of the larynx. After explaining the most important information, what is the nurse's best action? Give the client his or her cell phone number. Refer the client to a social worker or psychologist. Provide the client with audiovisual materials about the surgery. Reassure the client and family that outcomes are nearly always positive.

Provide the client with audiovisual materials about the surgery. Explanation: Informational materials (written and audiovisual) about the surgery are given to the client and family for review and reinforcement. The nurse never gives personal contact information to the client. Nothing in the scenario indicates that a referral to a social worker or psychologist is necessary. False reassurance must always be avoided.

A client seeks medical attention for a hoarseness that has lasted for more than 2 weeks. Which additional finding indicates to the nurse that the client may need to be evaluated for cancer of the larynx? Nausea Facial pain Sore throat Deviated trachea

Sore throat Explanation: Hoarseness of more than 2 weeks' duration is a common symptom in the client with cancer of the larynx because the tumor impedes the action of the vocal cords during speech. Nausea is not a symptom of laryngeal cancer. Pain radiating to the ear and not to the face may occur if metastasis has occurred. A lump may be felt in the neck but the trachea is not affected.

Which intervention regarding nutrition is implemented for clients who have undergone laryngectomy? Use enteral feedings after the procedure Offer plenty of thin liquids when intake resumes Season food to suit an increased sense of taste and smell Recommend the long-term use of zinc lozenges

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 client 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.

The nurse advises a patient who sustained a fractured nose during an automobile accident that surgery will be necessary. Due to significant facial edema, surgery would be scheduled: Within 24 hours. Within 1 week. In 2 to 3 weeks. After 1 month.

Within 1 week. Explanation: Surgical reduction of a fracture should occur immediately. However, with significant edema present, surgery can be delayed up to 7 days to allow time for the fluid to resolve. After 1 week, if the fracture is misaligned, rhinoplasty will be necessary to reshape the external appearance of the nose.

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.

A nurse is teaching a client with recurrent rhinosinusitis. What medication will the nurse instruct the client to take at the first sign of symptoms? guaifenesin acetaminophen oxymetazoline nasal spray naproxen

guaifenesin Explanation: The client should take a decongestant (e.g., guaifenesin [Mucinex]) 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 (Tylenol) and nonsteroidal anti-inflammatory drugs, such as naproxen (Aleve). Over-the-counter nasal oxymetazoline sprays (Afrin) may cause rebound congestion.

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.

An older male client with a history of chronic laryngitis reports a persistent hoarseness. What condition is the client at risk to develop? laryngeal cancer adenoiditis coryza peritonsillar abscess

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 women. The client's history of chronic laryngitis may also predispose the client 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. Coryza is another term for the common cold. Symptoms include sneezing, sore throat, and nasal congestion. Clients with a peritonsillar abscess experience difficulty and pain with swallowing, fever, malaise, ear pain, and difficulty talking.

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. inhaling polluted air isn't a risk factor for laryngeal cancer. laryngeal cancer occurs primarily in women. adenocarcinoma accounts for most cases of laryngeal cancer.

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.