L7 27: Nursing Management: Upper Respiratory Problems

Physiological Integrity 8. A patient who has been diagnosed with sleep apnea has CPAP ordered. Which of these nursing actions in the plan of care can the RN delegate to a nursing assistant? a. Monitor the patient's oxygen saturation during the night. b. Remind the patient to apply the CPAP at bedtime. c. Assess for fatigue or depression caused by poor sleep. d. Teach the patient how to apply the CPAP mask.

B Rationale: Reminding a patient about previously taught self-care activities is within the education level and scope of practice for a nursing assistant. Assessment and teaching are skills that require higher-level nursing education and scope of practice. Cognitive Level: Application Text Reference: pp. 542-543 Nursing Process: Planning

Physiological Integrity 2. When the nurse removes a nasogastric (NG) tube that has been in place for 7 days, the patient develops a nosebleed. To control the bleeding, the nurse should initially a. place the patient in a sitting position with the head hyperextended. b. apply ice compresses over the patient's nose and cheeks. c. pinch the soft lower portion of the nose for about 10 to 15 minutes. d. pack the nares with ribbon gauze to apply pressure to the area.

C Rationale: The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. The patient should be sitting and leaning forward. Ice compresses may be helpful in decreasing bleeding but is not the most appropriate initial action. If the bleeding persists, the nares may be packed with ribbon gauze by the health care provider. Cognitive Level: Application Text Reference: p. 534 Nursing Process: Implementation

Physiological Integrity 15. A patient is discharged from the hospital with a tracheostomy tube for long-term airway management. The nurse determines that teaching related to care of the tracheostomy has been effective when the patient says, a. "It will be several months before I will be able to change my tracheostomy tube at home." b. "My medical insurance will cover the cost of sterile gloves and catheters for suctioning." c. "I should maintain a liquid diet as long as I have the tracheostomy tube in place." d. "If I have thick mucus, I can instill about a teaspoon of water into my tracheostomy tube."

A Rationale: It takes several months for the formation of a fully healed tract, so the patient is taught to leave the tracheostomy tube in place for several months. Clean (rather than sterile) gloves and catheters are used for suctioning at home to decrease expense. Semisoft foods, rather than liquids, are the easiest to swallow. Water should not be instilled into the tracheostomy; thick secretions may indicate the need for more fluid intake or humidification. Cognitive Level: Application Text Reference: p. 547 Nursing Process: Evaluation

Physiological Integrity 14. When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to a. use a manometer to assure cuff pressure is at an appropriate level. b. verify the health care provider's order for the amount of cuff pressure required. c. fill the balloon until no leakage around the cuff is auscultated. d. check the pilot balloon after inflation to assure that it is firm.

A Rationale: Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal capillaries. A firm pilot balloon indicates that the cuff is inflated but does not assess for overinflation. A health care provider's order is not required to determine safe cuff pressure. A minimal leak technique is an alternate means for cuff inflation, but this technique does allow a small air leak around the cuff and increases the risk for aspiration. Cognitive Level: Application Text Reference: p. 544 Nursing Process: Implementation

Physiological Integrity 17. The nurse is obtaining a health history from a 67-year-old patient with a 40 pack-year smoking history, complaints of hoarseness and tightness in the throat, and difficulty swallowing. Which question is most important for the nurse to ask? a. How much alcohol do you drink in an average week? b. Do you have a history of using chewing tobacco or snuff? c. Do you use antihistamines for upper airway congestion? d. Have you had frequent streptococcal throat infections?

A Rationale: Prolonged alcohol use is associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Use of chewing tobacco or snuff is associated with oral cancers rather than throat cancers. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but this is not the priority assessment to obtain at this time. Streptococcal throat infections may also cause these clinical manifestations, but patients will also complain of pain and fever. Cognitive Level: Application Text Reference: pp. 551, 553 Nursing Process: Assessment

Physiological Integrity 3. When teaching the patient with allergic rhinitis about management of the condition, the nurse explains that a. identification and avoidance of triggers are the best way to avoid allergic reactions. b. use of oral antihistamines for a few weeks before the allergy season may prevent reactions. c. corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use. d. OTC antihistamines cause sedation, so prescription antihistamines are usually ordered.

A Rationale: The most important intervention is to assist the patient to identify and avoid potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Nonsedating antihistamines are available OTC. Cognitive Level: Application Text Reference: pp. 535-536 Nursing Process: Implementation

Safe and Effective Care Environment 10. When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow, it is important to a. suction the patient's mouth and trachea before deflation of the cuff. b. measure the amount of air removed from the cuff during deflation. c. deflate the cuff during the inhalation phase of the respiratory cycle. d. clean the inner cannula of the tracheostomy tube before deflation.

A Rationale: The patient's mouth and trachea should be suctioned before the cuff is deflated to prevent aspiration of oral secretions. The amount of air needed to inflate the cuff varies and is adjusted by measuring cuff pressure or using the minimal leak technique, not by measuring the volume of air removed from the cuff. The cuff is deflated during patient exhalation so that secretions will be forced into the mouth rather than aspirated. There is no need to clean the inner cannula before cuff deflation. Cognitive Level: Application Text Reference: p. 547 Nursing Process: Implementation

Physiological Integrity 16. A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective? a. "I will need to buy a water bottle to carry with me." b. "Until the radiation is complete, I may have diarrhea." c. "Alcohol-based mouthwashes will help clean oral ulcers." d. "I can use lotions to moisturize the skin on my throat."

A Rationale: Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not effect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Use of lotions on skin being radiated is avoided. Cognitive Level: Application Text Reference: p. 555 Nursing Process: Evaluation

Physiological Integrity MULTIPLE RESPONSE 1. The teaching plan for a patient with acute sinusitis will need to include which of the following interventions? (Select all that apply.) a. You will be more comfortable if you keep your head in an upright position. b. Application of cool compresses to your face will improve sinus drainage. c. OTC antihistamines can be used to relieve congestion and inflammation. d. Taking a hot shower will increase sinus drainage and decrease pain. e. Blowing the nose forcefully should be avoided to decrease nosebleed risk. f. Saline nasal spray can be made at home and used to wash out secretions.

A, D, F Rationale: Maintaining an upright posture decreases sinus pressure and the resulting pain. The steam and heat from a shower will help thin secretions and improve drainage. Patients can use either OTC sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Cool compresses will not improve drainage. Antihistamines are drying to the mucosa and tend to thicken secretions, making them more difficult to expel. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions. Cognitive Level: Application Text Reference: p. 541 Nursing Process: Implementation

Health Promotion and Maintenance 5. A patient who has sleep apnea and has been using CPAP for 2 weeks returns to the sleep clinic and tells the nurse, "My sleep has not improved at all." Which response by the nurse is most appropriate? a. "CPAP takes more than a few weeks to achieve the maximum effect." b. "Have you been using the CPAP every night?" c. "Do you want to talk to the doctor about surgery?" d. "Perhaps the CPAP pressure should be increased to a higher level."

B Rationale: Although CPAP is very effective in improving sleep quality in patients with sleep apnea, many patients are noncompliant with this therapy. The nurse should be sure that the patient is actually using the CPAP. When CPAP is used, the effects on sleep quality are immediate. Surgery may be an appropriate therapy for the patient, but suggesting surgery would not be an appropriate first action by the nurse in this situation. CPAP using higher pressures will make it more difficult for the patient to exhale and is likely to decrease compliance with therapy. Cognitive Level: Application Text Reference: p. 543 Nursing Process: Assessment

Physiological Integrity 13. A patient with a tracheostomy is to use a fenestrated tracheostomy tube to provide for speech. Which of the following interventions will be included in the plan of care? a. Placing the decannulation cap in the tube before cuff deflation b. Assessing the patient's ability to swallow without choking c. Keeping the cuff inflated to prevent aspiration of secretions d. Leaving the inner cannula in place to facilitate suctioning

B Rationale: Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords. Cognitive Level: Application Text Reference: pp. 544, 550 Nursing Process: Implementation

Physiological Integrity 6. The nurse is reviewing the charts for these patients who are scheduled in October for their yearly physical examinations. The nurse will plan on administration of the influenza vaccine injection to the a. 24-year-old patient who has allergies to penicillin and the cephalosporins. b. 30-year-old patient who is takes corticosteroids for rheumatoid arthritis. c. 36-year-old patient who has a history of a positive PPD test. d. 42-year-old patient who has a 20 pack-year smoking history.

B Rationale: It is recommended that patients who are immune compromised receive yearly influenza vaccinations. The corticosteroid use by the 30-year-old increases the risk for infection. The other three individuals are not at increased risk for influenza. Current guidelines suggest that healthy individuals between ages 5 and 49 receive intranasal immunization with live, attenuated influenza vaccine (FluMist). Cognitive Level: Application Text Reference: p. 539 Nursing Process: Planning

Psychosocial Integrity 21. After completing discharge instructions for a patient with a total laryngectomy, the nurse determines that additional instruction is needed when the patient says, a. "I can participate in most of my prior fitness activities except swimming." b. "I must keep the stoma covered with a loose sterile dressing at all times." c. "I need to eat nutritious meals even though I can't smell or taste very well." d. "I should wear a Medic Alert bracelet that identifies me as a neck breather."

B Rationale: The stoma may be covered with clothing or a loose dressing, but this is not essential. The other patient comments are all accurate and indicate that the teaching has been effective. Cognitive Level: Application Text Reference: p. 557 Nursing Process: Evaluation

Physiological Integrity 22. The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to treat a nosebleed. Which of these assessments will require the most immediate action by the nurse? a. The patient's temperature is 100.1° F. b. The nose appears red and swollen. c. The oxygen saturation is 89%. d. The patient complains of pain rated as 7 of a 10-point scale.

C Rationale: Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to assess further for these complications. The other assessment data also indicate a need for nursing action but not as immediately as the fall in O2 saturation. Cognitive Level: Application Text Reference: p. 535 Nursing Process: Assessment

Safe and Effective Care Environment 9. An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene? a. The student preoxygenates the patient for 2 minutes before suctioning. b. The student applies suction for 10 seconds while withdrawing the catheter. c. The student puts on clean gloves and uses a sterile catheter to suction. d. The student inserts the catheter about 5 inches into the tracheostomy tube.

C Rationale: Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other student actions do not require intervention by the RN. Although the patient may not need 2 minutes of preoxygenation, this would not be unsafe; 10 seconds of suction is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube. Cognitive Level: Application Text Reference: pp. 545, 549 Nursing Process: Implementation

Health Promotion and Maintenance 7. The nurse notes all of these findings in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider? a. Fever of 100.4° F (38° C) b. Myalgia and persistent headache c. Diffuse crackles in the lungs d. Sore throat and frequent cough

C Rationale: The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical symptoms of influenza and are treated with supportive care measures such as OTC pain relievers and increased fluid intake. Cognitive Level: Application Text Reference: p. 539 Nursing Process: Assessment

Physiological Integrity 12. A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. The nurse's first action should be to a. assess the patient's oxygen saturation and call the health care provider. b. ventilate the patient with a manual bag mask until the health care provider arrives. c. insert the obturator and attempt to reinsert the tracheostomy tube. d. position the patient in an upright position with the neck extended.

C Rationale: The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. The patient should be placed in a semi-Fowler's position, but the neck should remain in a neutral position. Cognitive Level: Application Text Reference: p. 547 Nursing Process: Implementation

Physiological Integrity 23. After teaching a patient with allergic rhinitis how to use a nasal inhaler, the nurse observes the patient self-administering a medication with the inhaler. Which patient action indicates that more teaching is needed? a. The patient gently blows the nose before using the inhaler. b. The patient tilts the head back before inhaling the medication. c. The patient breathes out slowly through the nostrils following inhaler use. d. The patient waits a few seconds before exhaling after using the inhaler.

C Rationale: The nurse needs to teach the patient to breathe out through the mouth after inhaler use to avoid exhaling some of the medication. The other patient actions indicate that the teaching has been effective. Cognitive Level: Application Text Reference: p. 539 Nursing Process: Evaluation

Health Promotion and Maintenance 18. A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "How will I talk after the surgery?" The best response by the nurse is, a. "You will breathe through a permanent opening in your neck, but you will not be able to communicate orally." b. "You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak normally." c. "You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration." d. "You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed."

C Rationale: Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are available to restore communication. Although the ability to communicate orally is changed, it would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible. Cognitive Level: Application Text Reference: pp. 556-557 Nursing Process: Implementation

Physiological Integrity OTHER 1. The nurse enters the room of a patient who has just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? a. The NG tube is disconnected from suction and clamped off. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The patient is lying in a lateral position with the head of the bed flat. d. The Hemovac in the neck incision contains 200 ml of bloody drainage.

C, B, D, A Rationale: The patient should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action. Then the Hemovac should be drained because the 200 ml of drainage will decrease the amount of suction in the Hemovac and could lead to incisional swelling and poor healing. Finally, the NG tube should be reconnected to suction to prevent gastric dilation, nausea, and vomiting. Cognitive Level: Analysis Text Reference: pp. 552, 556 Nursing Process: Implementation

Physiological Integrity 11. A spontaneously breathing patient who has a cuffed tracheostomy tube in place has new orders for speech therapy and a soft diet. To evaluate whether the patient can safely have the cuff deflated to promote speaking and make swallowing easier, the nurse deflates the cuff and then a. assesses whether the patient is able to talk. b. monitors for symptoms of respiratory distress. c. asks the patient to swallow a small amount of clear liquid and auscultates the lungs for the presence of crackles. d. has the patient drink a small amount of grape juice and observes for coughing and the presence of colored sputum.

D Rationale: Assessing the ability of the patient to drink a colored fluid, such as grape juice, will provide evidence that the patient will not aspirate. Even if the patient is able to talk, aspiration may occur. Because the patient is already breathing spontaneously, deflating the cuff would not cause respiratory distress. Although aspiration may lead to complications such as pneumonia, the absence of lung crackles immediately after drinking a clear liquid is not a clear indicator that aspiration has not occurred. Cognitive Level: Application Text Reference: pp. 544, 547 Nursing Process: Implementation

Physiological Integrity 20. A nursing diagnosis of body image disturbance related to loss of control of personal care is identified for a patient with a total laryngectomy and radical neck dissection. The nurse evaluates that an expected outcome for the problem has been met when the patient a. wears clothing that minimizes the disfigurement caused by surgery. b. lets the spouse provide hygiene and stoma care. c. asks that only family members be allowed to visit. d. learns to remove and clean the laryngectomy tube independently.

D Rationale: Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and the body image disturbance is at least partially resolved. Allowing the spouse to provide care, allowing family members to visit, and wearing clothing that masks the body changes are outcomes that do not directly address this nursing diagnosis. Cognitive Level: Application Text Reference: p. 555 Nursing Process: Evaluation

1. A patient has undergone a rhinoplasty to correct nasal deformities resulting from trauma during an automobile accident. The nursing intervention that is most appropriate postoperatively is to a. teach the patient to use aspirin or acetaminophen to control the postoperative pain. b. remind the patient that the nasal packing will not be removed for several weeks. c. reassure the patient that the nose will look normal when the swelling subsides. d. instruct the patient to keep the head elevated for 48 hours to minimize swelling.

D Rationale: Maintaining the head in an elevated position will decrease the amount of nasal swelling. Although acetaminophen may be appropriate, aspirin and the NSAIDs will increase the risk for postoperative bleeding. The nasal packing is usually removed the next day. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result. Cognitive Level: Application Text Reference: p. 534 Nursing Process: Implementation

Physiological Integrity 19. A patient returns from surgery with a tracheostomy tube after a total laryngectomy and radical neck dissection. In caring for the patient during the first 24 hours after surgery, the priority nursing action is to a. avoid changing the tracheostomy ties. b. clean the inner cannula every 8 hours. c. monitor for bleeding around the stoma. d. assess the airway and breath sounds.

D Rationale: The most important goals post-tracheotomy are to maintain the airway and ensure adequate oxygenation. Assessment of the airway and breath sounds is the priority action. Maintenance of the tracheostomy ties, cleaning the inner cannula, and checking for bleeding are also appropriate nursing actions but are not of as high a priority. Cognitive Level: Analysis Text Reference: pp. 553, 556 Nursing Process: Implementation

Health Promotion and Maintenance 4. After discussing care of upper respiratory infections (URI) and prevention of secondary infections with a patient who has a URI, the nurse determines that additional teaching is needed when the patient says a. "I will drink lots of juices and other fluids to stay hydrated." b. "I will watch for changes in nasal secretions or the sputum that I cough up." c. "I can take acetaminophen (Tylenol) to treat discomfort." d. "I can use my nasal decongestant spray until the congestion is all gone."

D Rationale: The nurse should clarify that nasal decongestant sprays should be used for no more than 3 days to prevent rebound vasodilation and congestion. The other responses indicate that the teaching has been effective. Cognitive Level: Application Text Reference: p. 538 Nursing Process: Evaluation