Chapter 22: Management of Patients with Upper Respiratory Tract Disorders

Which is the priority nursing diagnosis for a client undergoing a laryngectomy?

Ineffective airway clearance

The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently?

Airway patency

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

A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to

Check the clear fluid for glucose. (CSF contains glucose)

Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?

Continuous positive airway pressure (CPAP)

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?

Hypercapnia (excessive CO2)

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

The nurse assesses a patient for possible acute pharyngitis. Which of the following clinical manifestations are consistent with this diagnosis? Select all that apply.

Red pharyngeal membranes Swollen lymphoid follicles White-purple exudates on the back of the throat A temperature >100.4°F

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

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

A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever, and dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may predispose the client to sinusitis?

interference with sinus drainage

Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has?

Laryngeal cancer

The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?

Total laryngectomy

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

amoxicillin-clavulanic acid.

Which assessment finding puts a client at increased risk for epistaxis?

cocaine use

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

ensure mouth breathing

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

nuchal rigidity

Stiffness of the neck or inability to bend the neck is referred to as

nuchal rigidity

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

2 to 12 days

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."

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

Apply direct continuous pressure.

The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Auscultate lung sounds.

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

Hoarseness for 2 weeks

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

A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in her teaching?

"Cover the stoma whenever you shower or bathe."