Question 1

The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider?

Accepted Answer

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.

Question 2

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?

Accepted Answer

This patient needs suctioning now 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.

Question 3

Which patient in the ear,nose,and throat (ENT)clinic should the nurse assess first?

Accepted Answer

The patient's clinical manifestation of a muffled voice suggests a possible peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment and potential treatment. The other patients do not have diagnoses or symptoms that indicate any life-threatening problems.

Question 4

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?

Accepted Answer

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.

Question 5

A patient arrives in the ear,nose,and throat clinic complaining of a piece of tissue being "stuck up my nose" and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first?

Accepted Answer

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.

Question 6

Which statement by the patient indicates that teaching has been effective for a patient scheduled for radiation therapy of the larynx?

Accepted Answer

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.

Question 7

Which nursing action could the registered nurse (RN)working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN)caring for a patient with a permanent tracheostomy?

Accepted Answer

Suctioning of a stable patient can be delegated to LPNs/LVNs. Patient assessment and patient teaching should be done by the RN.

Question 8

After being hit by a baseball,a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider?

Accepted Answer

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 any complications.

Question 9

The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement,if made by the patient,indicates that the teaching was successful?

Accepted Answer

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.

Question 10

After a laryngectomy,a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?

Accepted Answer

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.

Question 11

Which action should the nurse take first when a patient develops epistaxis?

Accepted Answer

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.

Question 12

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?

Accepted Answer

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 also indicate a need for nursing action but not as immediately as the low O₂ saturation.

Question 13

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask?

Accepted Answer

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.

Question 14

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?

Accepted Answer

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.

Question 15

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?

Accepted Answer

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.

Question 16

The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan?

Accepted Answer

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 rhinitis (common cold)can be prevented by washing hands,but allergic rhinitis cannot.

Question 17

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse indicates that this identified problem is resolving?

Accepted Answer

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.

Question 18

The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed?

Accepted Answer

The stoma may be covered with clothing or a loose dressing,but this is not essential. An occlusive dressing will completely block the patient's airway. The other patient comments are all accurate and indicate that the teaching has been effective.

Question 19

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?

Accepted Answer

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.

Question 20

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?

Accepted Answer

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.

Quiz 26: Upper Respiratory Problems