MedSurg 8.10.15
The nurse is suctioning a client who had a laryngectomy. What is the MAXIMUM amount of time the nurse should suction the client?
10 sec Rationale: Suctioning for longer than 10 seconds may decrease the oxygen level and cause the patient to become hypoxic
Which of the following home care instructions would be appropriate for a client with a laryngectomy?
Adequate humidity should be provided in the home to keep secretions moist. Rationale: Mouth care is important to prevent drying of the mucous membranes and should be performed frequently throughout the day, especially before and after meals, to help stimulate the appetite. The client may eat any food that can be chewed and swallowed comfortably. The client may resume physical activity as tolerated.
The client who has had a total laryngectomy appears withdrawn and depressed. The client keeps the curtain drawn, refuses visitors, and indicates a desire to be left alone. Which nursing intervention would MOST likely be therapeutic for this client>
Encourage the client to express feelings non-verbally and in writing. Rationale: Discussing the client's behavior with his wife may not reveal his feelings. Exploring future plans in not appropriate at this time because more information about the client's behavior is needed before proceeding to this level. The nurse can respect the client's need for privacy while also encouraging him to express his feelings.
A client with allergic rhinitis is instructed on the correct technique for using an intranasal inhaler. Which of the following statements would demonstrate to the nurse that the client understands the instructions?
I should hold one nostril closed while I insert the spray into the other nostril Rationale: Use of the inhaler is not limited to mornings and bedtime. The canister should be shaken immediately before use. The inhaler tip should be inserted into the nostril and pointed toward the outside of the nostril wall to maximize inhalation of the medication
Pseudoephedrine (Sudafed) has been prescribed as a decongestant. Which of the following is a possible adverse effect of this drug?
Restlessness Rationale: The most common CNS adverse effects include restlessness, dizziness, tension, anxiety, insomnia, and weakness. Common CV adverse effects include tachycardia, hypertension, palpitations, and arrhythmia.
Symptoms of an upper respiratory tract infection
Sore throat, nasal congestion, headache, pain, snotty nose, sinus pressure
What areas of education should the nurse provide employees in a factory making products that cause respiratory irritants to reduce the risk of laryngeal cancer?
Stop smoking and limit alcohol intake
Can an upper respiratory tract infection turn into a lower respiratory tract infection?
The bacteria can travel the airway
Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection?
The client will experience less nasal obstruction and discharge. Rationale: Daily intake of fluids should be increased to more than 1L every day to liquefy secretions. The temperature should be below 100F or 37.8C with no chills or diaphoresis. A productive cough with chest pain indicates a pulmonary infection not an upper respiratory tract infection.
How do you distinguish upper respiratory tract infections from lower respiratory tract infections to patients?
diagrams, relating the symptoms with the patient, putting them side by side and describing the differences
A nurse is completing the health history for a client who has been taking echinacea for a head cold. The client asks "Why isn't this helping me feel better?". What is the most appropriate response?
There is limited information as to the effectiveness of herbal products. Rationale: Antibiotics are effective against bacteria and the head cold may be viral. An uncomplicated upper respiratory tract infection subsides within 2-3 weeks. There may be drug-drug interactions between herbal and prescription drugs.
