test 3 med s resp. prep u
A nurse is providing care to a client who is receiving mechanical ventilation via a cuffed endotracheal tube. When measuring cuff pressure, which reading would the nurse interpret as reducing the client's risk for injury?
20cm H2O
Hemilaryngectomy Supraglottic laryngectomy Partial laryngectomy Total laryngectomy
n 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.
hypertension manifestations
"silent killer", fatigue, headache, malaise, and dizziness stroke, vision. (major cause of renal disease)
nonrebreather mask
100% besides intubation
idea of using cuffed endotracheal tube is to achieve a seal between the cuff and the trachea with a pressure sufficient enough to prevent aspiration but not so much that tracheal blood flow is impeded. An acceptable cuff pressure ranges from
20 to 30 cm H2O
2 pounds in
24 hr
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:
A permanent tracheal stoma would be necessary.
A client has undergone a laryngectomy. The nurse notes evidence of wound breakdown. The nurse understands that the client is at a high risk for developing?
Carotid artery hemorrhage
Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?
Continuous positive airway pressure (CPAP)
Which of the following interventions does a nurse implement for patients with empyema?
Encourage breathing exercises.
You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis?
Encourage deep breathing every 2 hours.
A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is considered an early clinical indicator.
Hoarseness
During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?
Hypercapnia Repetitive apneic events result in hypoxia and hypercapnia, which triggers a sympathetic response (increased heart rate and decreased tone and contractility of smooth muscle).
Which clinical manifestation of hemorrhage is related to carotid artery rupture?
Increased pulse rate
THE NURSES ROLE IN RESPIRATORY MANAGEMENT
Managing= Managing Respiratory Compromise Delivering= Oxygen when needed and knowing alternative devices and when to use Maintaining= patent airway Obtaining= sputum samples
A patient with a diagnosis of acute rhinosinusitis has approached the nurse and asked for advice about "rinsing out my sinuses with saltwater," a treatment that was suggested by a friend. The nurse's response should be premised on which of the following statements?
Nasal saline lavage can help to improve the patency of the sinuses.
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
Noisy breathing
Which type of sleep apnea is characterized by lack of airflow due to pharyngeal occlusion?
Obstructive
types of sleep apena
Obstructive Mixed Central
occurs usually in men, especially men who are older and overweight.
Obstructive sleep apnea
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
A young adult client has had a tonsillectomy and is in the immediate postoperative period. To make the client comfortable, the nurse intervenes by
Placing the client prone with the head turned to the side
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?
Tension pneumothorax
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
Total laryngectomy
While caring for a patient with an endotracheal tube the nurse recognizes that suctioning is required:
When adventitious breath sounds are auscultated
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
5 pounds in
a week
Complete or partial collapse of a lung or a section (lobe) of a lung.
atelectasis
Mixed sleep apnea is a combination of
central and obstructive apnea, with one apneic episode.
What adventitious lung sounds are significant for pulmonary edema?
crackles
Dysphasia
difficulty speaking
pharyngitis
inflammation of the throat
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
epistaxis
nose bleed Bleeding from the nose, either spontaneous or induced by nose picking or trauma.
Sp02 means what?
saturation of peripheral oxygen
Types of sleep apnea do not include a ?
simple classification
In central sleep apnea, the client demonstrates
simultaneous cessation of both airflow and respiratory movements.
The nurse in the ICU is caring for a client with a nasotracheal tube. Because of the tube placement, the nurse understands that the client is at risk for developing
sinus infection.