N355 Chapter 22: Management of Patients with Upper Respiratory Tract Disorders

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? -Assess capillary refill. -Monitor heart rhythm. -Obtain vital signs. -Auscultate lung sounds.

Correct response: Auscultate lung sounds. Explanation: Major goals of intubation are to improve respirations and maintain a patent airway for gas exchange. Regular auscultation of the lung fields is essential in confirming that air is reaching the lung fields for gas exchange. All other options are important to provide assessment data.

A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for: -Mild headache -Nausea -Hypertension -Nuchal rigidity

Correct response: Nuchal rigidity Explanation: Potential complications of acute bacterial rhinosinusitis are nuchal rigidity and severe headache. Hypertension may be a result of over-the-counter decongestant medications. Nausea may be a result of nasal corticosteroids.

A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is -cefprozil. -amoxicillin-clavulanic acid. -cefuroxime. -ampicillin.

Correct response: amoxicillin-clavulanic acid. Explanation: Amoxicillin-clavulanic acid (Augmentin) is the antibiotic of choice to treat ABRS. For patients who are allergic to penicillin, doxycycline (Vibramycin) or respiratory quinolones such as levofloxacin (Levaquin) or moxifloxacin (Avelox) can be used. 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 organism

Which assessment finding puts a client at increased risk for epistaxis? -History of nasal surgery -Use of a humidifier at night -Hypotension -Cocaine use

Correct response: Cocaine use Explanation: Using nasally inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased vascularity of the nasal passages. A dry environment (not a humidified one) increases the risk of epistaxis. Hypertension, not hypotension, increases the risk of epistaxis. A history of nasal surgery doesn't increase the risk of epistaxis.

The nurse is caring for a client admitted with a diagnosis of bacterial pharyngitis. The nurse anticipates the client will be ordered which medication? -Tylenol with codeine -Tylenol -Penicillin -Robitussin DM

Correct response: Penicillin Explanation: The treatment of choice for bacterial pharyngitis is penicillin. Penicillin V potassium taken for 5 days is the regimen of choice. Traditionally, penicillin was administered as a single injection; however, oral forms are now used more often and are as effective as and less painful than injections. Penicillin injections are recommended only if there is a concern that the client will not comply with therapy. Robitussin DM may be used as an antitussive. Aspirin or Tylenol, or Tylenol with codeine, may be given for severe sore throats.

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? -Take aspirin for nasal discomfort. -Administer normal saline nasal drops as ordered. -Avoid sports activities for 6 weeks. -Decrease the amount of daily fluids.

Correct response: 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.

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately? -Difficulty talking -Throat pain -Difficulty swallowing -Bleeding

Correct response: Bleeding Explanation: The nurse should instruct the client to report bleeding immediately. Delayed bleeding may occur when the healing membrane separates from the underlying tissue — usually 7 to 10 days postoperatively. Difficulty swallowing and throat pain are expected after a tonsillectomy and typically are present even before the client is discharged. Sudden difficulty talking wouldn't occur after discharge if the client could talk normally at the time of discharge, because swelling doesn't take that long to develop.

A nurse is caring for a client who has just had a total laryngectomy. What is part of the client's plan of care related to the surgery? -Keep the client flat in bed. -Develop an alternative communication method. -Encourage oral feedings as soon as possible. -Keep the tracheostomy cuff fully inflated.

Correct response: Develop an alternative communication method. Explanation: A client with a laryngectomy can't speak, but still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. After a laryngectomy, edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury as tracheal stenosis, the nurse ensures that the tracheostomy cuff is deflated (for a client with a cuffed tube) except for short periods, such as when the client is eating or taking medications. To decrease edema, the nurse should place the client in semi-Fowler's position.

Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require? -Family counseling -Referral for vocational training -Referral for counseling -Emotional support

Correct response: Emotional support Explanation: Clients with a malignancy of the larynx require emotional support before and after surgery and help in understanding and choosing an alternative method of speech. It does not require a referral for counseling or vocational training. It also does not require family counseling.

A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for: -Myalgias -Fever -Nausea -Headache

Correct response: Fever Explanation: The signs and symptoms described are consistent with acute pharyngitis. The nurse needs to assess for a fever higher than 39.3°C. Findings will help to determine if the client requires antibiotic therapy. The client may also experience headache, myalgias, and nausea. The nurse needs to assess for these symptoms also, and symptomatic treatment would then be provided.

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? -Encourage sweet foods. -Liberally season foods. -Offer plenty of thin liquids. -Initiate enteral feedings.

Correct response: 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.

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? -Total laryngectomy -Hemilaryngectomy -Supraglottic laryngectomy -Partial laryngectomy

Correct response: 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.

The nurse is assessing a client for obstructive sleep apnea (OSA). Which are signs and symptoms of OSA? Select all that apply. -Insomnia -Pulmonary hypotension -Evening headaches -Loud snoring -Polycythemia

Correct response: Polycythemia Loud snoring Insomnia Explanation: Signs and symptoms include excessive daytime sleepiness, frequent nocturnal awakening, insomnia, loud snoring, morning headaches, intellectual deterioration, personality changes, irritability, impotence, systemic hypertension, dysrhythmias, pulmonary hypertension, , polycythemia, and enuresis.

The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect? -Postoperative bleeding -Infection -Edema of the upper airway -Plugged tracheostomy tube

Correct response: Edema of the upper airway Explanation: With severe respiratory distress in a status post adenoidectomy client, the nurse would suspect an airway issue related to edema of the upper airway. The scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy tube.

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? -"Clean the tracheostomy tube with alcohol and water." -"Oral intake of fluids should be limited for 1 week only." -"Limit the amount of protein in the diet." -"Family members should continue to talk to the client."

Correct response: "Family members should continue to talk to the client." Explanation: Commonly, family members are reluctant to talk to the client who has had a total laryngectomy and can no longer speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing.

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

Correct response: "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 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.

Correct response: 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.

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 be connected to a negative-pressure ventilator." -"The ET tube will remain in place for at least a day postsurgery." -"The ET tube will maintain your airway while you're under anesthesia." -"The ET tube will be inserted through an opening in your trachea."

Correct response: "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.

Late symptoms of laryngeal cancer include which of the following. Select all that apply. -Dysphagia -Burning in throat -Sore throat -Persistent hoarseness -Dyspnea

Correct response: Dysphagia Dyspnea Persistent hoarseness Explanation: Later symptoms include dysphagia, dyspnea, unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath. Earlier, the patient may complain of a persistent cough or sore throat and pain and burning in the throat, especially when consuming hot liquids or citrus juices.

Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction? -Apply pressure to the convex portion of the nose -Apply a warm pack postoperatively -Ensure mouth breathing -Provide a splint postoperatively

Correct response: Ensure mouth breathing Explanation: For a client who has undergone surgery for a nasal obstruction, it is important for the nurse to emphasize that nasal packing will be in place postoperatively, necessitating breathing through the mouth. The nurse applies an ice pack to reduce pain and swelling and not a warm pack. The nurse recommends the use of a splint and the application of pressure to the convex portion of the nose in case of a nasal fracture.

Select the nursing diagnosis that would warrant immediate health care provider notification. -Deficient fluid volume related to decreased fluid intake and increased fluid loss secondary to diaphoresis associated with a fever -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 knowledge regarding prevention of upper airway infections, treatment regimens, the surgical procedure, or postoperative care

Correct response: 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.

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of: -1 to 3 months. -2 to 12 days. -3 to 6 months. -20 to 30 days.

Correct response: 2 to 12 days. Explanation: HSV-1 is transmitted primarily by direct contact with infected secretions. The time periods of 20 to 30 days, 1 to 3 months, and 3 to 6 months exceed the incubation period.

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

Correct response: 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)? -Ceftin -Levofloxacin -Amoxicillin -Keflex

Correct response: 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 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

Correct response: 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.

The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid -coughing. -wearing a scarf over the stoma. -wearing a plastic bib while showering. -swimming.

Correct response: swimming. Explanation: Swimming is not recommended because a client with a laryngectomy can drown without submerging his or her face. Special precautions are needed in the shower to prevent water from entering the stoma. Wearing a loose-fitting plastic bib over the tracheostomy or simply holding a hand over the opening is effective. The nurse also suggests that the client wear a scarf over the stoma to make the opening less obvious. The nurse encourages the client to cough every 2 hours to promote effective gas exchange.

A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis? -Apply direct continuous pressure. -Apply a moustache dressing. -Provide a nasal splint. -Place the client in a semi-Fowler's position.

Correct response: 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 nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to -Stay in bed when experiencing a fever -Place an ice collar on the throat to relieve soreness -Properly dispose of used tissues -Seek medical help if he experiences inability to swallow

Correct response: Seek medical help if he experiences inability to swallow Explanation: The client should seek medical assistance if swallowing is impaired to prevent aspiration. Following Maslow's hierarchy of needs, airway clearance is the highest priority.

A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client: -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.

Correct response: 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.

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

Correct response: 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.