ms chapter 20 caring for clients with upper respiratory disorders

The nurse is caring for a client with an upper respiratory disorder. The client states he has a hacky, nonproductive cough, which wakens him during the night. Which over-the-counter medication would the nurse suggest to diminish the cough during the night?

B.Dextromethorphan

A graduate practical nurse is caring for a client who has a tracheostomy tube. A seasoned nurse is assisting in providing guidance for completing tracheostomy care. When changing the ties, the client moves and dislodges the tube. Which of the following does the seasoned nurse do first?

B.Place a dilator in the stoma to maintain the opening.

The nurse is caring for the client who presents to the clinic with hoarseness for 2 months. Further testing revealed a diagnosis of laryngeal cancer with a treatment plan for a radical neck dissection. When reinforcing information provided by the physician to the client, which nursing instruction is most correct?

B.The physician removes lymph nodes, muscles, and tissue.

A client recently diagnosed with laryngeal cancer and awaiting a laryngectomy was encouraged to attend a support group prior to surgery. The client asked the nurse about the name of the laryngeal speech method where the client regurgitates swallows air and forms words with his lips. The nurse is correct to provide teaching on which method?

A.Esophageal speech

The nurse is presenting about upper respiratory infections at an educational event for a local community group. What should the nurse be sure to include regarding cold tablets containing first-generation antihistamines?

C. They can cause drowsiness.

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?

C.Auscultate lung sounds.

The nurse is an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would the nurse be sure to include in the workshop? Select all that apply.

alcohol tobacco industrial pollutants

The nurse is providing discharge instructions to a client diagnosed with postoperative tonsillectomy and adenoidectomy. Which discharge instructions would the nurse include? Select all that apply.

b. avoid carbonated fluids c. gradually increase fluids than a soft food d. apply ice collar to neck area e. gargle with warm saline water

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?

b. transillumination of the sinus

The nurse in the walk-in clinic is caring for a client complaining of a sore throat and fever for 3 days. Upon inspection, the nurse notes the client's throat is red, with raised, white patches. Which nursing assessment should be stressed?

b. voiding

A nurse is caring for a client following nasal surgery. Which assessment finding best indicates current bleeding?

c. frequent swallowing

The nurse is caring for a client in a physician's office whose X-ray of the sinus reveals exudate in the maxillary sinus. Which equipment must the nurse have present in the room?

c. irrigation equipment

The emergency department nurse is assessing a client following a motor vehicle accident. The nurse notes facial deformities with swelling and bleeding and a clear drainage coming from the nares. Which diagnostic test is completed to determine whether the clear drainage is cerebrospinal fluid?

c. test fluid with dextrostix

The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, "Elevate the head of the bed 45°." Which nursing goal is met in this assessment?

c. the client will have decreased edema

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

A. Develop an alternate method of communication.

The nurse is caring for a client with a new tracheostomy. Select two nursing diagnosis that have the highest priority when caring for this patient.

A. Ineffective Airway Clearance related to increased secretions D. Impaired Gas Exchange related to shallow breathing and anxiousness

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 a client diagnosed with coryza, possibly from the rhinovirus. Vital signs are temperature: 101.2°F, pulse: 72 beats/minute, respirations: 28 breaths/minute, and blood pressure: 112/70 mm Hg. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are course in the bases. Which afternoon assessment finding suggests the advancement to an infectious process?

C. Temperature rise

A client visits the physician's office concerned about possible sleep apnea. The client states he lives alone and fears that he will not awaken from sleep. The client states that he has many symptoms which may indicate sleep apnea. Which symptom, stated by the client, is not a symptom of sleep apnea?

D."I have pressure in the middle of my chest at night."

A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy?

D."Tell my wife about it, I do not want to touch it."

The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

Noisy breathing

The nurse is performing a preoperative assessment on a client who is scheduled for a tonsillectomy. Why would the nurse ask the client about the use of herbal supplements?

They may prolong bleeding.

The nurse is caring for a client following sinus surgery. When assessing the client, the nurse asks him how many fingers are being held up. Why does the nurse assess postoperative visual acuity?

To assess damage to the optic nerve

The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?

a. administer an over the counter decongestant

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

a. airway patency

The nurse is mentoring a new graduate nurse, caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would the nurse respond? Select all that apply.

aspiration, infection, injury to the laryngeal nerve

The nurse is caring for a client status after adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect?

c. edema of the upper airway

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?

c. hoarseness for two weeks

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?

d. "I was chewing ice chips all day long"

The nurse is providing suggestions to a client diagnosed with the effects of coryza. Which home remedy is appropriate when combined with medical treatment for pharyngitis?

d. salt water gargle

The nurse is caring for a client status post-nasal polypectomy. What would the nurse instruct this client to report?

excessive swallowing

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply.

B. Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 C.Nasal flaring with abdominal retractions D.Increased respiratory effort E.Lung sounds of wheezing

The nurse is caring for a client experiencing laryngeal trauma. Upon assessment, swelling and bruising is noted to the neck. Which breath sound is anticipated?

B. Audible stridor without using a stethoscope

The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?

B. Sudden restlessness

The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?

B.A face mask

The nurse is receiving a client in the postanesthesia care unit (PACU) diagnosed with postoperative tonsillectomy and adenoidectomy. The unlicensed assistive personnel is assisting the client from the stretcher to the bed. The client remains drowsy from anesthesia. In which position would the nurse instruct the unlicensed assistive personnel to place the client?

a. on a side