Upper Respiratory Problems Lewis Chapter 26

A school nurse is providing information to high school students about influenza prevention. What should the nurse emphasize in teaching to prevent the transmission of the virus? (Select all that apply.) 1. Cover the nose when coughing. 2. Obtain an influenza vaccination. 3. Stay at home when symptomatic. 4. Drink noncaffeinated fluids daily. 5. Obtain antibiotic therapy promptly.

1. Cover the nose when coughing. 2. Obtain an influenza vaccination. 3. Stay at home when symptomatic. Rationale: Covering the nose and mouth when coughing is an effective way to prevent the spread of the virus. Obtaining an influenza vaccination helps prevent the flu. Staying at home helps prevent direct exposure of others to the virus. Drinking fluids helps liquefy secretions but does not prevent influenza. Antibiotic therapy is not used unless the patient develops a secondary bacterial infection.

The nurse observes clear nasal drainage in a patient newly admitted with facial trauma with a nasal fracture. What is the nurse's priority action? 1. Test the drainage for the presence of glucose. 2. Suction the nose to maintain airway clearance. 3. Document the findings and continue monitoring. 4. Apply a drip pad and reassure the patient this is normal.

1. Test the drainage for the presence of glucose. Rationale: Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF. Suctioning should not be done. Documenting the findings and monitoring are important after notifying the health care provider. A drip pad may be applied, but the patient should not be reassured that this is normal.

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when the tracheostomy tube is expelled by coughing. What is the priority action by the nurse? 1. Suction the tracheostomy opening. 2. Maintain the airway with a sterile hemostat. 3. Use an Ambu bag and mask to ventilate the patient. 4. Insert the tracheostomy tube obturator into the stoma.

2. Maintain the airway with a sterile hemostat. Rationale: As long as the patient is not in acute respiratory distress after dislodging the tracheostomy tube, the nurse should use a sterile hemostat to maintain an open airway until a sterile tracheostomy tube can be reinserted into the tracheal opening. The tracheostomy is an open surgical wound that has not had time to mature into a stoma. If the patient is in respiratory distress, the nurse will use an Ambu bag and mask to ventilate the patient temporarily.

The nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to an employee. Which question should the nurse ask before administration of this vaccine? 1. "Are you allergic to chicken?" 2. "Could you be pregnant now?" 3. "Did you ever have influenza?" 4. "Have you ever had hepatitis B?"

2. "Could you be pregnant now?" Rationale: The live attenuated influenza vaccine (LAIV) is given by nasal spray and approved for healthy people age 2 to 49 years. The LAIV is given only to nonpregnant, healthy people. The inactivated vaccine is given by injection and is approved for use in people 6 months or older. The inactivated vaccine can be used in pregnancy, in people with chronic conditions, or in people who are immunosuppressed. Influenza vaccination is contraindicated if the person has a history of Guillain-Barré syndrome or a hypersensitivity to eggs.

When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priority assessment? 1. Patient comfort 2. Airway patency 3. Incisional drainage 4. Blood pressure and heart rate

2. Airway patency Rationale: Remember the ABCs with prioritization. Airway patency is always the highest priority and is essential for a patient undergoing surgery surrounding the upper respiratory system. Comfort, drainage, and vital signs follow the ABCs in priority.

A patient has a tracheostomy tube after reconstructive surgery for invasive head and neck cancer. What is most important for the nurse to assess before performing tracheostomy cannula care? 1. Level of consciousness 2. Quality of breath sounds 3. Presence of the gag reflex 4. Tracheostomy cuff pressure

2. Quality of breath sounds Rationale: Before performing tracheostomy care, the nurse will auscultate lung sounds to determine the presence of secretions. To prevent aspiration, secretions must be cleared either by coughing or by suctioning before performing tracheostomy cannula care.

Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? 1. Assessing the need for suctioning 2. Suctioning the patient's oropharynx 3. Assessing the patient's swallowing ability 4. Maintaining appropriate cuff inflation pressure

2. Suctioning the patient's oropharynx Rationale: Providing the person has been trained in correct technique, the UAP may suction the patient's oropharynx. Assessing the need for suctioning should be performed by an RN or licensed practical nurse. An RN should perform a swallowing assessment and maintain cuff inflation pressure.

A patient with a history of tonsillitis reports difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? 1. Bilateral erythema of especially large tonsils 2. Temperature 102.2° F, diaphoresis, and chills 3. Contraction of neck muscles during inspiration 4. β-Hemolytic streptococcus in the throat culture

3. Contraction of neck muscles during inspiration Rationale: Contraction of neck muscles during inspiration indicates that the patient is using accessory muscles for breathing and is in serious respiratory distress. The reddened and enlarged tonsils indicate pharyngitis. The increased temperature, diaphoresis, and chills indicate an infection, which could be β-hemolytic streptococcus or fungal infection, but not an emergency situation for the patient.

The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect to teach the patient about? 1. Nasal packing 2. Epistaxis balloon 3. Gastrostomy tube 4. Peripheral skin care

3. Gastrostomy tube Rationale: Because 50% of patients with head and neck cancer are malnourished before treatment begins, many patients need enteral nutrition via a gastrostomy tube because the effects of treatment make it difficult to take in enough nutrients orally, whether surgery, chemotherapy, or radiation is used. Nasal packing could be used with epistaxis or with nasal or sinus problems. Peripheral skin care would not be expected because it is not related to head and neck cancer.

The nurse is caring for a patient with a tracheostomy. What is the priority nursing assessment for this patient? 1. Electrolyte levels and daily weights 2. Assessment of speech and swallowing 3. Respiratory rate and oxygen saturation 4. Pain assessment and assessment of mobility

3. Respiratory rate and oxygen saturation Rationale: The priority assessment in the care of a patient with a tracheostomy focuses on airway and breathing. These assessments supersede the nurse's assessments that may also be necessary, such as nutritional status, speech, pain, and swallowing ability.

A patient is being discharged from the emergency department after being treated for epistaxis. In teaching first aid measures in the event the epistaxis would recur, what measures should the nurse suggest? (Select all that apply.) 1. Tilt patient's head backwards. 2. Apply ice compresses to the nose. 3. Tilt head forward while sitting upright. 4. Pinch the entire soft lower portion of the nose. 5. Lying down until 15 minutes after the bleeding ceases

3. Tilt head forward while sitting upright. 4. Pinch the entire soft lower portion of the nose. Rationale: Use simple first aid measures to control nosebleeds. These include: (1) placing the patient in a sitting position, leaning slightly forward with head tilted forward and (2) applying direct pressure by squeezing the entire soft lower portion of the nose (nostrils) together for 5 to 15 minutes. Tilting the head back does not stop the bleeding but allows the blood to enter the nasopharynx, which could result in aspiration or nausea or vomiting from swallowing blood. Lying down also will not decrease the bleeding.

The nurse teaches a patient about the use of budesonide intranasal spray for seasonal allergic rhinitis. The nurse determines that medication teaching is successful if the patient makes which statement? 1. "My liver function will be checked with blood tests every 2 to 3 months." 2. "The medication will decrease the congestion within 3 to 5 minutes after use." 3. "I may develop a serious infection because the medication reduces my immunity." 4. "I will use the medication every day of the season whether I have symptoms or not."

4. "I will use the medication every day of the season whether I have symptoms or not." Rationale: Budesonide should be started 2 weeks before pollen season starts and used on a regular basis, not as needed. The spray acts to decrease inflammation and the effect is not immediate as with decongestant sprays. At recommended doses, budesonide has only local effects and will not result in immunosuppression or a systemic infection. Zafirlukast (Accolate) is a leukotriene receptor antagonist and may alter liver function tests (LFTs). LFTs must be monitored periodically in the patient taking zafirlukast.

The nurse teaches a patient with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which statement, if made by the patient, indicates further teaching is required? 1. "I should avoid using ibuprofen for pain and discomfort." 2. "It is important for me to take my blood pressure medication every day." 3. "I will sit down and pinch the tip of my nose for at least 10 to 15 minutes." 4. "If I get a nosebleed, I will lie down flat and raise my feet above my heart."

4. "If I get a nosebleed, I will lie down flat and raise my feet above my heart." Rationale: A simple measure to control epistaxis (or a nosebleed) is for the patient to remain quiet in a sitting position. Another measure is to apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes. Aspirin and nonsteroidal antiinflammatory drugs such as ibuprofen increase the bleeding time and should be avoided. Elevated blood pressure makes epistaxis more difficult to control. The patient should continue with antihypertensive medications as prescribed.

The nurse is reviewing the health history of a patient with laryngeal cancer. Which finding would the nurse expect? 1. Family history of lung cancer 2. Recent inhalation of noxious fumes 3. Frequent straining of the vocal cords 4. Chronic use of alcohol and tobacco products

4. Chronic use of alcohol and tobacco products Rationale: Tobacco use causes 85% of head and neck cancers. Excess alcohol use is another major risk factor. Other risk factors include exposure to the sun, asbestos, industrial carcinogens, marijuana use, radiation therapy to the head and neck, and poor oral hygiene.

The nurse is scheduled to administer seasonal influenza vaccinations to the residents of a long-term care facility. What would be a contraindication to the administration of the vaccine to a resident? 1. Age older than 80 years 2. History of upper respiratory infections 3. Chronic obstructive pulmonary disease (COPD) 4. History of a severe allergic reaction to the vaccine

4. History of a severe allergic reaction to the vaccine Rationale: Contraindications to vaccination include a history of severe allergic reactions to previous flu vaccine. Patients with anaphylactic hypersensitivity to eggs should discuss the vaccine with their HCP, as alternatives for vaccinating patients with egg allergies are now available. Advanced age and a history of respiratory illness are not contraindications for influenza vaccination.

A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement? 1. Apply an external splint to the nose. 2. Insert plastic nasal implant surgically. 3. Humidify the air for mouth breathing. 4. Maintain surgical packing in the nose.

4. Maintain surgical packing in the nose. Rationale: A goal that is common to nursing and medical management of a patient after rhinoplasty is to prevent the formation of a septal hematoma and potential infections resulting from a septal hematoma. Therefore, the nurse helps to keep the nasal packing in the nose. The packing applies direct pressure to oozing blood vessels to stop postoperative bleeding. A medical goal includes realigning the fracture with an external or internal splint. The nurse helps maintain the airway by humidifying inspired air because the nose is unable to do so following surgery because it is swollen and packed with gauze.

The patient seeks relief from the symptoms of an upper respiratory infection (URI) lasting for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis? 1. Coughing 2. Fever, chills 3. Dust allergy 4. Maxillary pain

4. Maxillary pain Rationale: The nurse should assess the patient for sinus pain or pressure as a clinical indicator of acute sinusitis. Coughing and fever are nonspecific clinical indicators of a URI. A history of an allergy that is likely to affect the upper respiratory tract is supportive of the sinusitis diagnosis but is not specific for sinusitis

A patient is admitted for joint replacement surgery and has a permanent tracheostomy. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? 1. Suction the tracheostomy. 2. Check stoma site for skin breakdown. 3. Complete tracheostomy care using sterile technique. 4. Provide oral care with a toothbrush and tonsil suction tube.

4. Provide oral care with a toothbrush and tonsil suction tube. Rationale: Oral care (for a stable patient with a tracheostomy) can be delegated to UAP. A registered nurse would be responsible for assessments (e.g., checking the stoma for skin breakdown) and tracheostomy suctioning and care.

The patient has decided to use the voice rehabilitation that offers the best speech quality even though it must be cleaned regularly. The nurse knows that this is what kind of voice rehabilitation? 1. Electromyography 2. Intraoral electrolarynx 3. Neck type electrolarynx 4. Transesophageal puncture

4. Transesophageal puncture Rationale: The transesophageal puncture provides a fistula between the esophagus and trachea with a one-way valved prosthesis to prevent aspiration from the esophagus to the trachea. Air moves from the lungs and vibrates against the esophagus, and words are formed with the tongue and lips as the air moves out the mouth. The electromyography and both electrolarynx methods produce low-pitched mechanical sounds.

Which patient in the ear, nose, and throat clinic should the nurse assess first? a. A patient who reports having a sore throat and has a muffled voice. b. A patient with a history of a total laryngectomy whose stoma is red. c. A patient who has a "scratchy throat" and a positive rapid strep antigen test. d. A patient who is receiving radiation for throat cancer and has severe fatigue.

ANS: A A muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. A tracheal stoma is normally red. Strep throat and fatigue do not indicate life-threatening problems. DIF:

A patient arrives in the emergency department with a possible nasal fracture after being hit by a baseball. Which finding by the nurse is most important to report to the health care provider? a. Clear nasal drainage b. Report of nasal pain c. Bilateral nose swelling and bruising d. Inability to breathe through the nose

ANS: A Clear nasal drainage may indicate a meningeal tear with leakage of cerebrospinal fluid. This would place the patient at risk for complications such as meningitis. The other findings are typical with a nasal fracture and do not indicate complications.

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would determine if the cuff has been properly inflated? a. Use a hand-held manometer to measure cuff pressure. b. Review the health record for the prescribed cuff pressure. c. Suction the patient through a fenestrated inner cannula to clear secretions. d. Insert the decannulation plug before removing the nonfenestrated inner cannula.

ANS: A Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patient's airway is occluded. A health care provider's order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings.

The nurse is caring for a hospitalized older patient who has nasal packing in place after a nosebleed. Which assessment finding will require the most immediate action by the nurse? a. The oxygen saturation is 89%. b. The nose appears red and swollen. c. The patient reports level 8 (0 to 10 scale) pain. d. The patient's temperature is 100.1° F (37.8° C).

ANS: A Older patients with nasal packing are at risk of aspiration or airway obstruction. An O2 saturation of 89% should alert the nurse to further assess for these complications. The other assessment data indicate a need for nursing action but not as immediately as the low O2 saturation.

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient reports hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask? a. "How much alcohol do you drink in an average week?" b. "Do you have a family history of head or neck cancer?" c. "Have you had frequent streptococcal throat infections?" d. "Do you use antihistamines for upper airway congestion?"

ANS: A Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Patients with streptococcal throat infections will also have pain and a fever.

Which statement by the patient indicates that teaching has been effective for a patient scheduled for radiation therapy of the larynx? a. "I will need to buy a water bottle to carry with me." b. "I should not use any lotions on my neck and throat." c. "Until the radiation is complete, I may have diarrhea." d. "Alcohol-based mouthwashes will help clean my mouth."

ANS: A Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect 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. Prescribed lotions and sunscreen may be used on radiated skin, although they should not be used just before the radiation therapy.

Acute laryngitis

an inflammation of the voice box, most often caused by a virus. • The main sign is hoarseness, which may be accompanied by total loss of voice. • Treatment is supportive, and focuses on resting the voice, acetaminophen for throat discomfort, cough suppressants, and increasing fluid intake.

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination? (Select all that apply.) a. A 76-yr-old nursing home resident b. A 36-yr-old female patient who is pregnant c. A 42-yr-old patient who has a 15 pack-year smoking history d. A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis e. A 24-yr-old patient who has allergies to penicillin and cephalosporins

ANS: A, B, D Individuals who are pregnant, residents of nursing homes, or are immunocompromised or who have chronic medical conditions should receive inactivated vaccine by injection. The corticosteroid use by the 30-year-old patient increases the risk for infection. Current guidelines suggest that healthy individuals between 6 months and age 49 years receive intranasal immunization with live, attenuated influenza vaccine.

The nurse assumes care of a patient who 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 patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage.

ANS: A, B, D, C 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 wound drain should be drained because the 200 mL of drainage will decrease the amount of suction in the wound drain 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.

The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session? (Select all that apply.) a. Decongestants can be used to relieve swelling. b. Avoid blowing the nose to decrease the nosebleed risk. c. Taking a hot shower will increase sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position.

ANS: A, C, D, E The steam and heat from a shower will help thin secretions and improve drainage. Decongestants can be used to relieve swelling. Patients can use either over-the-counter sterile saline solutions or home-prepared saline solutions to thin and remove secretions. Maintaining an upright posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot shower or using the saline spray is recommended to expel secretions.

The nurse provides discharge instructions for a patient after a total laryngectomy. Which statement by the patient indicates that additional instruction is needed? a. "I can participate in fitness activities except swimming." b. "I must keep the stoma covered with an occlusive dressing." c. "I need to have smoke and carbon monoxide detectors installed." d. "I will wear a Medic-Alert bracelet to identify me as a neck breather."

ANS: B An occlusive dressing will completely block the patient's airway. 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.

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/VN) caring for a patient with a permanent tracheostomy? a. Assess the patient's risk for aspiration. b. Suction the tracheostomy when directed. c. Teach the patient to provide tracheostomy self-care. d. Determine the need for tracheostomy tube replacement.

ANS: B Suctioning of a stable patient can be delegated to LPNs/VNs. The RN should perform patient assessment and patient teaching.

Which information will be most important for the nurse to communicate to the health care provider about an older patient who has influenza? a. Fever of 100.4° F (38° C) b. Diffuse crackles in the lungs c. Sore throat and frequent cough d. Myalgia and persistent headache

ANS: B 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 manifestations of influenza and are treated with supportive care measures such as over-the-counter pain relievers and increased fluid intake.

Which action should the nurse take first when a patient develops epistaxis? a. Pack the affected nare tightly with an epistaxis balloon. b. Apply squeezing pressure to the nostrils for 10 minutes. c. Obtain silver nitrate that may be needed for cauterization. d. Instill a vasoconstrictor medication into the affected nare.

ANS: B The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils. Application of cold packs may decrease blood flow to the area but will not be sufficient to stop bleeding. Cauterization, nasal packing, and vasoconstrictors are medical interventions that may be needed if pressure to the nares does not stop the bleeding, but these are not the first actions to take for a nosebleed.

The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan? a. Using oral antihistamines for 2 weeks before the allergy season may prevent reactions. b. Identifying and avoiding environmental triggers are the best way to prevent symptoms. c. Frequent hand washing is the primary way to prevent spreading the condition to others. d. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use.

ANS: B The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Acute viral rhinopharyngitis (common cold) can be prevented by washing hands, but allergic rhinitis cannot.

The nurse discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed? a. "I will drink lots of juices and other fluids to stay well hydrated." b. "I can use nasal decongestant spray until the congestion is gone." c. "I can take acetaminophen (Tylenol) to treat my sinus discomfort." d. "I will watch for changes in nasal secretions or the sputum that I cough up."

ANS: B 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.

When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking? a. Teach the patient about the use of expectorants. b. Use a swab to obtain a sample for a rapid strep antigen test. c. Discuss the need to rinse the mouth out after using any inhalers. d. Teach the patient to avoid nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: B The patient's clinical manifestations are consistent with streptococcal pharyngitis, and the nurse will anticipate the need for a rapid strep antigen test or cultures (or both). Because patients with streptococcal pharyngitis usually do not have a cough, use of expectorants will not be anticipated. Rinsing out the mouth after inhaler use may prevent fungal oral infections, but the patient's assessment data are not consistent with a fungal infection. NSAIDs are often prescribed for pain and fever relief with pharyngitis.

Allergic rhinitis Initial manifestations

are sneezing; watery, itchy eyes and nose; and thin, watery nasal discharge leading to congestion.

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? a. Leave the tracheostomy inner cannula inserted at all times. b. Place the decannulation cap in the tube before cuff deflation. c. Assess the ability to swallow before using the fenestrated tube. d. Inflate the tracheostomy cuff during use of the fenestrated tube.

ANS: C 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 when using a fenestrated tube.

A patient who had a total laryngectomy has previously expressed hopelessness about the loss of control over personal care. Which information obtained by the nurse indicates that this identified problem is resolving? a. The patient allows the nurse to suction the tracheostomy. b. The patient's spouse provides the daily tracheostomy care. c. The patient asks to learn how to clean the tracheostomy stoma. d. The patient uses a communication board to request "No Visitors."

ANS: C Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.

If a nasal fracture is present, nursing responsibilities including

assessing the patient's ability to breathe and ascertaining that hemorrhage and leakage of cerebrospinal fluid (CSF) are not present.

After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Arrange for arterial blood gases to be drawn immediately. b. Cover stoma with sterile gauze and ventilate through stoma. c. Attempt to reinsert the tracheostomy tube with the obturator in place. d. Assess the patient's oxygen saturation and notify the health care provider.

ANS: C The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. 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. Assessing the patient's oxygenation is an important action, but it is not as appropriate until there is an established airway.

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action? a. Monitor the incision for bleeding. b. Maintain adequate IV fluid intake. c. Keep the patient in semi-Fowler's position. d. Teach the patient to suction the tracheostomy.

ANS: C The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for bleeding are important, but maintaining an open airway is the priority. During the immediate postoperative period, the patient with a laryngectomy requires frequent suctioning of the tracheostomy tube. The patient may be taught to suction after the tracheostomy is stable, if needed, but not during the immediate postoperative period.

The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a. Encourage increased incentive spirometer use. b. Encourage the patient to increase oral fluid intake. c. Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning.

ANS: C This patient needs suctioning to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary; 30 seconds is recommended. Incentive spirometer use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the most accurate response by the nurse? 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 talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed." c. "You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration." d. "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."

ANS: C 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 lost. Artificial voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed, so normal speech is impossible.

A patient arrives in the ear, nose, and throat clinic with foul-smelling nasal drainage from the right nare, reporting a piece of tissue being "stuck up my nose." Which action should the nurse take first? a. Notify the clinic health care provider. b. Obtain aerobic culture specimens of the drainage. c. Ask the patient about how the cotton got into the nose. d. Have the patient occlude the left nare and blow the nose.

ANS: D Because the highest priority action is to remove the foreign object from the nare, the nurse's first action should be to assist the patient to remove the object. The other actions are also appropriate but should be done after attempting to clear the nose.

The nurse provides discharge instructions after a rhinoplasty. Which statement by the patient indicates that the teaching was successful? a. "My nose will look normal after 24 to 48 hours." b. "I can take 800 mg ibuprofen every 6 hours for pain." c. "I will remove and reapply the nasal packing every day." d. "I will elevate my head for 48 hours to minimize swelling."

ANS: D Maintaining the head in an elevated position will decrease the amount of nasal swelling. Nonsteroidal antiinflammatory drugs, such as ibuprofen, increase the risk for postoperative bleeding and should not be used postoperatively. The patient would not remove or reapply nasal packing, which is usually removed by the surgeon on the day after surgery. Although return to a preinjury appearance is the goal of the surgery, it is not always possible to achieve this result, especially in the first few weeks after surgery.

The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care? a. Assess patient for allergies to penicillin antibiotics. b. Teach the patient to sleep in a warm, dry environment. c. Avoid giving the patient warm food or warm liquids to drink. d. Teach patient to "swish and swallow" prescribed oral nystatin.

ANS: D Oral or pharyngeal fungal infections are treated with nystatin solution. The goal of the "swish and swallow" technique is to expose all the oral mucosa to the antifungal agent. Warm liquids may be soothing to a sore throat. The patient should be taught to use a cool mist humidifier. There is no need to assess for penicillin allergy because C. albicans infection is treated with antifungals.

The best method for determining the risk for aspiration in a patient with a tracheostomy is to a. consult a speech therapist for swallowing assessment b. have the patient drink plain water and assess for coughing c. ask the patient to rate the perceived degree of swallowing difficulty. d. assess for sputum changes 48 hours after the patient drinks small amount of blue dye.

Correct answer: a Rationale: The ability to swallow secretions without aspiration has traditionally been evaluated with the use of blue dye; however, this method is no longer recommended. Instead, clinical assessment by a speech therapist, videofluoroscopy, or fiberoptic endoscopic evaluations of swallow are recommended. Patients should begin swallowing with thickened liquids, not plain water. Ability to swallow should be assessed with the cuff deflated, because cuff inflation may interfere with swallowing ability.

While in the recovery room, a patient with a total laryngectomy is suctioned and has bloody mucus with some clots. Which nursing interventions would apply? (select all that apply) a. notify the health care provider at once b. place the patient in semi-fowler's position c. use a bag-valve-mask (BVM) and begin rescue breathing for the patient d. instill 10 mL of normal saline into the tracheostomy tube to loosen secretions e. continue patient assessment, including O2 saturation, respiratory rate, and breath sounds.

Correct answer: b, e Rationale: Secretions are initially blood-tinged and then decrease in amount and become less bloody over time. Placing the patient in semi-Fowler's position will facilitate drainage. Normal saline through the tracheostomy tube is not recommended to help with removal of thickened secretions because it causes hypoxia and may contribute to the development of ventilatorassociated pneumonia (VAP). There is no sign that the patient has respiratory distress, so use of the bag-valve-mask is not appropriate

A patient is seen at the clinic for a nosebleed, which is controlled by placement of an anterior nasal packing. During discharge teaching, the nurse teaches the patient to a. use aspirin for pain relief b. remove the packing later that day c. avoid vigorous nose blowing and strenuous activity. d. insert more packing into the nose if rebleeding occurs.

Correct answer: c Rationale: The nurse should teach the patient about home care before discharge: to avoid vigorous nose blowing, strenuous activity, lifting, and straining for 4 to 6 weeks; to sneeze with the mouth open; and to avoid the use of aspirin-containing products. You would not teach the patient to insert more packing into a nose with packing already in-situ.

Which nursing action would be of highest priority when suctioning a patient with a tracheostomy? a. auscultating lung sounds after suctioning is complete. b. giving antianxiety medications 30 minutes before suctioning c. instilling 5mL of normal saline into the tracheostomy tube before suctioning. d. assessing the patient's oxygen saturation before, during, and after suctioning.

Correct answer: d Rationale: A patient with a tracheostomy is at risk for hypoxemia during and after suctioning. Pre-oxygenate patients with 100% FIO2 prior to suctioning. Monitor the patient's O2 status before, during, and after suctioning. Routine instillation of normal saline via ET tube or tracheostomy is no longer recommended.

A patient with allergic rhinitis reports severe nasal congestion; sneezing; and watery, itchy eyes and nose at various times of the year. When teaching the patient about how to control these symptoms, the nurse teaches the patient to a. avoid all intranasal sprays and oral antihistamines. b. limit the usage of nasal decongestant spray to 10 days. c. use oral decongestants at bedtime to prevent symptoms during the night. d. keep a diary of when the allergic reaction occurs and what precipitates it.

Correct answer: d Rationale: An important intervention involves identifying and avoiding triggers of allergic reactions. The nurse should have the patient keep a diary of times when the allergic reaction occurs and of the activities that precipitate the reaction

When planning healthcare teaching to prevent or detect early head and neck cancer, which people would the priority to target? (Select all that apply) a. 65 year old man who has used chewing tobacco most of his life. b. 45 year old rancher who uses snuff to stay awake while driving his herds of cattle c. 21 year old college student who drinks beer on weekends with his fraternity brothers. d/ 78 year old women who has been drinking liquor since her husband died 15 years ago. e. 22 year old women who has been diagnosed with human papilloma virus of the cervix.

Correct answers: a, b, d, e Rationale: Tobacco use causes 85% of head and neck cancers. Excess alcohol consumption and sun exposure are other risk factors. Head and neck cancers in those younger than 50 years of age have been associated with human papilloma virus (HPV) infection.

Appropriate discharge teaching for the patient with a permanent tracheostomy after a total laryngectomy for cancer would include (Select all that apply) a. encouraging regular exercise such as swimming b. washing around the stoma daily with a moist washcloth c. encouraging participation in postlaryngectomy support group. d. providing pictures and "hands-on" instruction for tracheostomy care. e. teaching how to hold breath and trying to gag to promote swallowing reflex.

Correct answers: b, c, d Rationale: Although regular exercise is important, shoulder and arm exercises are contraindicated. The nurse would teach the patient not to swim, as water entering the laryngeal stoma would risk choking and aspiration. All the other activities identified (including cleaning around the stoma daily with a damp, moist washcloth, providing pictures and "hands-on" time to practice for tracheostomy care, and encouraging the patient to join a support group with other laryngectomees) are appropriate.

A patient is seen at the clinic with feve, muscle aches, sore throat with yellowish exudate, and headache. The nurse anticipates that the interprofessional management will include (select all that apply) a. antiviral agents to treat influenz b. treatment with antibiotics starting ASAP c. a throat culture or rapid strep antigen test. d. supportive care, including cool, bland liquids e. comprehensive history to determine possible cause.

Correct answers: c, d, e Rationale: The goals of nursing management are infection control, symptom relief, and prevention of secondary complications. Drugs are not prescribed until the cause is known. Unnecessary antibiotic use leads to the development of antibiotic-resistant organisms. A thorough history and a throat culture help identify the cause. Encourage the patient with pharyngitis to increase fluid intake. Cool, bland liquids and gelatin do not irritate the pharynx; citrus juices are often irritating.

Head and Neck cancer

This category of tumors arises from the mucosal surfaces of the paranasal sinuses, oral cavity, or nasopharynx, oropharynx, or larynx. • Early signs and symptoms of head and neck cancer vary with the tumor location. Difficulties in chewing, swallowing, moving the tongue or jaw, and breathing are typically late symptoms. Unintentional weight loss and pain are late symptoms. • Choice of treatment for head and neck cancer is based on exact location of tumor, disease stage, patient age and general health, cosmetic and functional (e.g., ability to talk, swallow, and chew) considerations, urgency of treatment, and patient choice. • Stages I and II cancers are potentially curable with single-modality radiation therapy or larynx sparing surgery. • Patients with advanced disease (stages III and IV) are treated with various combinations of surgery, radiation, chemotherapy, and targeted therapy. Surgery typically involves a total laryngectomy with a permanent tracheostomy. • After radical neck surgery, the patient may be unable to take in nutrients through the normal route because of swelling, the location of sutures, or difficulty with swallowing. Enteral feeding is used to maintain adequate nutrition. • Nursing care revolves around maintaining an effective airway, decreasing risk for aspiration and infection, promoting adequate nutrition and communication, managing pain, and promoting psychosocial adaptation.

Peritonsillar abscess

a complication of acute pharyngitis, may threaten the airway if severe. Treatment includes IV antibiotics, needle aspiration, drainage, or surgery.

tracheostomy

a surgically created opening in the anterior trachea to establish an airway. • Other indications for a tracheostomy are to (1) bypass an upper airway obstruction, (2) facilitate removal of secretions, (3) permit long-term mechanical ventilation, and (4) facilitate weaning from mechanical ventilation. • Care of the patient with a tracheostomy tube can be divided into 2 phases: acute care and chronic care. • A wide variety of tracheostomy tubes are available. You must provide care specific to the type of tracheostomy tube present. • Nursing care for any tracheostomy patient focuses on maintaining an effective airway, decreasing the risk for aspiration, and promoting verbal communication and self-care management.

Seasonal rhinitis

caused by allergies to pollens from trees, flowers, grasses, or weeds.

A deviated septum is a

deflection of the normally straight nasal septum that is most commonly caused by trauma to the nose.

Laryngeal polyps

develop on the vocal cords because of vocal abuse or irritation. • The most common sign is hoarseness. • They are treated conservatively with voice rest and adequate hydration. Surgical removal may be indicated for large polyps, which may cause dyspnea.

Sinusitis

develops when the exit from the sinuses is narrowed or blocked by inflammation or swelling of the mucosa. Accumulating secretions provide a rich medium for growth of bacteria, viruses, and fungi, all of which may cause infection.

Allergic rhinitis Drug therapy

involves the use of oral H1-antihistamines, corticosteroids, decongestants, and leukotriene receptor antagonists (LTRAs). Intranasal drugs include antihistamines, anticholinergics, corticosteroids, cromolyn, and decongestants.

Airway obstruction

is a medical emergency. Interventions to reestablish a patent airway include the obstructed airway (Heimlich) maneuver, cricothyroidotomy, ET intubation, and tracheostomy.

Acute pharyngitis

is an acute inflammation of the pharyngeal walls that may include the tonsils, palate, and uvula. • Symptoms range in severity from a "scratchy throat" to pain so severe that swallowing is difficult. Both viral and streptococcal infections appear as a red and edematous pharynx, with or without patchy exudates, so appearance is not always diagnostic. • The goals of nursing management for acute pharyngitis are infection control, symptomatic relief, and prevention of secondary complications.

Allergic rhinitis

is the reaction of the nasal mucosa to a specific allergen.

Acute viral rhinopharyngitis

known as the common cold, is an infection of the upper respiratory tract. It can be caused by more than 200 different viruses. • Rest, oral fluids, proper diet, antipyretics, and analgesics are recommended. • During the cold season, tell patients with a chronic illness or a compromised immune status about measures to decrease the risk of getting a cold.

Chronic sinusitis

lasts longer than 12 weeks and is a persistent infection usually associated with allergies and nasal polyps. Although there may be facial or dental pain, nasal congestion, and increased drainage, severe pain and purulent drainage are often absent.

Nasal polyps can cause

obstruction and speech distortion, necessitating surgical removal.

Perennial rhinitis

occurs from exposure to environmental allergens such as animal dander, dust mites, molds, and cockroaches.

Epistaxis

or a nosebleed, has a wide variety of causes. Treat nosebleeds with simple measures, including direct pressure (squeezing the nostrils tightly) with the patient sitting upright, first.

Treatment of sinusitis

supportive care, antibiotics, and the use of ancillary medications to relieve symptoms, including oral or topical decongestants, nasal corticosteroids, analgesics, and saline nasal spray.

Rhinoplasty

the surgical reconstruction of the nose, is performed for cosmetic reasons or to improve airway function when trauma or developmental deformities result in nasal obstruction.

Acute sinusitis

typically begins within 1 week of an upper respiratory infection and lasts less than 4 weeks. Symptoms include significant pain over the affected sinus, purulent nasal drainage, nasal obstruction, congestion, fever, and malaise.

Influenza

typically has an abrupt onset with systemic symptoms of chills, fever, anorexia, malaise, and generalized myalgia which may be accompanied by a headache, cough, rhinorrhea, and sore throat. • Supportive care is directed at providing relief of symptoms and preventing pneumonia and other secondary infections. • Antivirals such as zanamivir (Relenza), oseltamivir (Tamiflu), and peramivir (Rapivab) are used to prevent and treat influenza A and B. • To combat the chance of developing influenza, 2 types of flu vaccines are available: inactivated and live, attenuated. • Advocate for the use of influenza vaccination in all patients older than 6 months of age, but especially for those at high risk. • Health care workers should be vaccinated to prevent transmission of influenza to highrisk persons.