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Med-Surg Chapter 26
Terms in this set (98)
A patient with acute viral rhinitis has asked the nurse about medications that can be taken to relieve symptoms. Which statement by the patient reflects a need for further instruction?
Decongestant sprays should not be used for more than three days to prevent rebound nasal congestion. Antibiotics may not be effective if the patient still has the cold. Saline nasal spray can be used to relieve congestion. The patient should not drive if taking an antihistamine.
The patient has an acute nasal fracture. What action by the nurse is best to maintain the patient's airway?
The nursing management goal for a patient with a nasal fracture is to maintain the airway by keeping the patient sitting upright. Applying ice to face and nose will reduce edema and bleeding and therefore indirectly assist with maintaining the airway, but sitting upright is paramount. Acetaminophen will provide analgesia but will not maintain the airway in a patient with a nasal fracture. Taking a hot shower will lead to increased swelling and should be avoided in the first 48 hours after a nasal fracture.
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?
Although current vaccines are highly purified and hypersensitivity reactions are extremely uncommon, a hypersensitivity to eggs precludes vaccination because the vaccine is produced in eggs. Advanced age and a history of respiratory illness are not contraindications for influenza vaccination.
A patient presents to the outpatient clinic with nasal trauma. On examination, the nurse finds localized pain, edema, epistaxis, and crepitus on palpation. The patient does not have nasal congestion. Which conditions should the nurse suspect?
Trauma to the nose is the major cause of nasal fracture. It is manifested as localized pain, edema, epistaxis, and crepitus on palpation. Acute sinusitis presents with pain over the affected sinuses, purulent nasal discharge, and fever. Allergic rhinitis presents with sneezing, itchy eyes and nose, and watery nasal discharge. Deviated nasal septum presents with nasal congestion.
A patient is taking phenylephrine nasal spray for nasal congestion. What should the nurse be sure to include when discussing side effects with the patient?
Phenylephrine is a nasal spray decongestant used in the treatment of rhinitis and sinusitis. Use of this nasal spray for more than three days can cause rebound nasal congestion. Ipratropium bromide is an anticholinergic nasal spray that can cause nasal dryness and irritation. Cromolyn spray can cause occasional burning or nasal irritation. Budesonide is a corticosteroid nasal spray that causes nasal burning and stinging.
A patient presents with a persistent runny nose, sneezing, and watery eyes. The patient also reports a recent onset of headache and nasal congestion. On further questioning, a nurse finds that the patient recently brought a cat home. What condition is the patient likely to have?
Allergic rhinitis can be caused by sporadic exposure to allergens such as animal dander. Symptoms such as runny nose, sneezing, and watery eyes caused by exposure to a cat are suggestive of allergic rhinitis. The symptoms of the common cold are similar to those of allergic rhinitis, but the common cold is not caused by pets. Symptoms such as a runny nose, sneezing, and watery eyes are not suggestive of septal deviation. These symptoms may be suggestive of influenza; however, influenza is not associated with pets.
A patient has been involved in a motor vehicle crash and has pain, swelling, and epistaxis. What is the priority nursing action in the care of this patient?
A patient can have edema, bleeding, nasal obstruction, and swelling of the nose due to trauma. Ice packs can promote vasoconstriction and reduce edema and bleeding. The nurse should apply ice packs at intervals of 10 to 20 minutes. The supine position can cause difficulty in breathing, so the nurse places the patient in an upright position to maintain the airway. The nurse will instruct the patient to avoid hot showers for the first 48 hours in order to reduce swelling. Aspirin is administered to reduce facial pain, but it can increase the clotting time and the risk of bleeding. The patient should be instructed to avoid the use of aspirin for the first 48 hours.
Which complication does the nurse suspect in a patient with breathing difficulty who has ecchymosis?
A patient with breathing difficulty may have sinusitis, rhinitis, or septal deviation. However, the patient has ecchymosis under the eyes, and the presence of ecchymosis is suggestive of orbital or basilar skull fracture. Rhinitis is suspected when the patient has a history of exposure to house molds, animal dander, or dust mites. Sinusitis is suspected when the nurse observes edematous mucosa and discolored purulent nasal drainage. Septal deviation is a deviation in the nasal septum.
A patient is admitted to an emergency department with injuries of the face and nose. A nurse notices a clear, pink-tinged discharge from the nostrils of the patient, even after controlling the nasal bleed. What could be the cause of the discharge?
A clear and pink-tinged discharge from the nose even after control of nasal bleeding suggests a cerebrospinal fluid (CSF) leak. It is an emergency situation and can lead to life-threatening complications. Skull fracture is manifested as ecchymosis of the eyes. There is no clear discharge in the event of a septal deviation or epistaxis.
The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. What should the nurse do first?
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 reports recurrent rhinitis and is prescribed diphenhydramine. Understanding the side effects associated with the medication, the nurse should instruct the patient to avoid which activity?
Diphenhydramine causes drowsiness and sedation. It can increase the risk of injury if the patient engages in activities like driving or operating machinery. Therefore, the patient should be asked not to drive while on the drug. Watching television, exercising, and sexual activity do not pose any danger to the patient during the treatment.
A student nurse is performing first aid measures in a patient who has had epistaxis for 15 minutes after being admitted to the hospital. Which step taken by the student nurse needs correction?
While providing first aid measurement to a patient with epistaxis, the nurse should place the patient in a sitting position because it will reduce the blood pressure in the veins of the nose and reduce bleeding, thereby preventing the patient from swallowing blood. Anterior packing is used to prevent the flow of blood when the bleeding does not stop after 15 minutes. The nurse should elevate the head of the patient to prevent the flow of blood, and for the clear visualization of the nostrils. The nurse should pinch the lower soft part of the nose because this intervention helps to send the pressure back to the bleeding point in the nasal septum and stops the flow of blood.
A patient reports sneezing, itchy eyes and nose, and watery nasal discharge to a nurse. The nurse finds pale, boggy, and swollen nasal turbinate. Which category of medication does the nurse expect to be included in the patient's prescription? Select all that apply.
Allergic rhinitis is the inflammation of nasal mucosa due to allergens such as pollens, animal dander, house molds, or dust mites. The patient with allergic rhinitis will have pale, boggy, and swollen nasal turbinates. Decongestants increase the vasoconstriction of the blood vessels and help to reduce nasal congestion. H1 antihistamines are used in the treatment of rhinitis because these medications bind with H1 receptors to block histamine binding and reduce inflammation. Anticoagulants, when administered to a patient with allergic rhinitis, increase bleeding time and aggravate the risk of epistaxis. Neuraminidase inhibitors are used in the treatment of influenza but do not help in relieving allergic rhinitis. Nonsteroidal antiinflammatory drugs increase bleeding time and pose a risk for epistaxis when used in a patient with rhinitis.
The nurse is working in the hospital during the flu season and knows that what is true?
Generalized myalgia or body aches are common flu symptoms. The onset of flu is abrupt and not insidious. Anorexia occurs, but not vomiting and diarrhea. Nuchal rigidity is impaired neck flexion resulting from muscle spasms of the neck and is related to meningeal irritation.
A patient with sinusitis is prescribed an anticholinergic nasal spray. Regarding which nasal spray should the nurse educate the patient?
Ipratropium bromide is an anticholinergic nasal spray used to treat sinusitis. Phenylephrine is a decongestant nasal spray used to treat rhinitis and sinusitis. Triamcinolone is a corticosteroid nasal spray used to treat sinusitis. Cromolyn spray is a mast cell stabilizer nasal spray used to treat rhinitis and sinusitis.
A patient arrives at the clinic with chills, a runny nose, sore throat, purulent sputum, and a cough. The nurse auscultates crackles in the left lung base. Which medication will the nurse expect the primary health care provider to prescribe for this patient?
The patient with influenza experiences chills, rhinorrhea, sore throat, purulent sputum, cough, and pneumonia. Zanamivir is a neuraminidase inhibitor used to treat influenza and is likely to be prescribed by the health care provider. This medication acts by preventing the budding and spreading of the influenza virus to other cells. Cetirizine is a second-generation antihistamine used to treat rhinitis and sinusitis. Fluticasone and ciclesonide are corticosteroids used to treat rhinitis or sinusitis.
A patient who experiences recurrent respiratory tract infections has chosen natural therapy. What is the most appropriate preparation for the nurse to use in this therapy?
Echinacea can reduce the incidence and duration of upper respiratory tract infections when used on a short-term basis. It should be used cautiously in patients with conditions affecting the immune system and also in asthmatic patients because it increases the risk of allergic reaction. Aloe is recommended for constipation. Ginger is used to treat nausea and vomiting during pregnancy. Hawthorn is used for mild to moderate heart failure.
What does the nurse teach a patient with sinusitis? Select all that apply.
The nurse instructs a patient with sinusitis to take adequate rest because it prevents fatigue and helps the body fight against infection-causing bacteria. The nurse also recommends that the patient drink plenty of water and remain hydrated in order to loosen nasal secretions. The nurse recommends that the patient perform large-volume nasal saline washes once or twice a day in order to facilitate the removal of nasal fluids. The nurse should suggest that the patient take hot showers twice a day to provide comfort. The patient should sleep with his or her head elevated because it helps drain the sinuses.
A nurse teaches home-care precautions to a patient who has anterior nasal packing at the time of hospital discharge. During follow-up visits, the nurse observes that the patient's condition is aggravated. Which action of the patient is responsible for this condition?
Anterior nasal packing is applied to prevent the flow of blood from the nose of a patient who has had nasal surgery or bleeding from the nose. After applying the nasal packing, the nurse will instruct the patient to avoid blowing through the nose vigorously, because this can cause pressure on the blood vessels and increase the risk of bleeding. Aspirin can increase bleeding and slows clotting time in a patient who has epistaxis; the nurse will instruct the patient to avoid the use of aspirin for pain. Sneezing with mouth open helps to reduce bruising and swelling of the nose. The nurse will instruct the patient to keep the nasal packing in place for few days because this helps in preventing bleeding.
A patient presents with epistaxis. Which interventions are appropriate to control the bleeding? Select all that apply.
To control epistaxis, the patient should be reassured and kept quiet. In epistaxis, approximately 90% of nosebleeds occur in the anterior portion of the nasal cavity and can be easily visualized. The patient should be made to sit, leaning slightly forward, with the head tilted forward. Direct pressure should be applied by pinching the entire soft lower portion of the nose against the nasal septum for 10 to 15 minutes. If bleeding does not stop within 15 to 20 minutes, consult the health care provider. Saline nasal sprays should not be used because these can dislodge the clot that is needed to stop the bleeding. Nose blowing will also remove the clot, which could lead to further bleeding.
Which clinical signs should the nurse monitor to ensure safety in a patient who has posterior nasal packing in the nose? Select all that apply.
Posterior nasal packing is applied to a patient to reduce bleeding from the nose. Posterior nasal packing can increase the risk of cardiovascular complications such as tachycardia and heart rhythm. The nurse should monitor heart rate and heart rhythm to check for complications. Posterior nasal packing can cause hypoxemia. Therefore the nurse should closely monitor the patient's respiratory rate. Posterior nasal packing does not alter thermoregulation. Therefore it does not result in hypothermia. Posterior nasal packing does not alter the red blood cell count.
A patient has a known allergy to dogs and is prescribed cromolyn spray. What should the nurse instruct the patient regarding the use of the spray?
Cromolyn is a mast cell stabilizer that inhibits the secretion of histamine and other inflammatory mediators. It is used to prevent symptoms of rhinitis and should be used 10 to 15 minutes before likely exposure to a known allergen. It is not recommended for daily use. Using the spray after allergen exposure would not be beneficial. Using the spray after the symptoms appear would also not help the patient.
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?
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.
An asthmatic patient comes to a clinic with exacerbation of asthma. The primary health care provider examines the patient for sinusitis. How would the nurse correlate asthma with sinusitis?
The postnasal drip in sinusitis may cause bronchoconstriction leading to an exacerbation of asthma. The triggers of asthma and sinusitis are different. The triggers that cause sinusitis may not necessarily trigger an asthma attack. The allergic reaction in sinusitis may not be a triggering factor for asthma. The breathing difficulty associated with sinusitis does not trigger asthma.
A patient is being discharged from the emergency department after being treated for epistaxis. In teaching the family first aid measures in the event the epistaxis would recur, what measures should the nurse suggest? Select all that apply.
First aid measures to control epistaxis include tilting the patient's head backwards and placing the patient in a sitting position, leaning forward. Applying ice compresses, pinching the soft lower portion of the nose or inserting a small gauze pad into the bleeding nostril should stop the bleeding within 15 minutes. Tilting the head back or forward does not stop the bleeding, but rather allows the blood to enter the nasopharynx, which could result in aspiration or nausea/vomiting from swallowing blood. Lying down also will not decrease the bleeding.
The nurse is caring for a patient with complaints of allergic nasal rhinitis. The nurse knows that the treatment includes what?
Adequate fluid intake is essential when the patient is taking antihistamines. Antibiotics are not appropriate for allergic rhinitis. Second-generation antihistamines are preferred over first-generation ones because of their nonsedating effects. Initially monotherapy is prescribed, and if that is not effective, then a two-drug combination may help.
A patient sustains an injury to the nose. Surgery is scheduled to repair the deviated nasal septum. The nurse expects to assess what patient symptoms? Select all that apply.
Common signs that are suggestive of a nasal septal deviation are nasal congestion, frequent nosebleeds, and difficulty in breathing through the nose. As a response to injury, blood circulation increases, causing congestion and frequent nosebleeds. A deviated septum may obstruct the air pathway, leading to difficulty in breathing through the nose. Nasal swelling and redness do not indicate deviated nasal septum but may indicate other injuries to the nose.
A patient is diagnosed with sinusitis. What type of corticosteroid does the nurse anticipate discussing with the patient prior to discharge? Select all that apply.
Flunisolide, triamcinolone, and fluticasone furoate are the corticosteroids used to treat sinusitis. Zileuton is a leukotriene-receptor inhibitor used to treat sinusitis. Clemastine is a first-generation antihistamine used to treat sinusitis.
A patient is diagnosed with a septal deviation. What common clinical manifestations will the nurse document relevant to this condition after assessment? Select all that apply.
Septal deviation is the deviation of a normal straight nasal septum. Epistaxis, facial pain, and nasal congestion are clinical manifestations of septal deviation. Ecchymosis is a clinical manifestation of nasal fracture. Discolored purulent nasal drainage is a clinical manifestation of acute sinusitis.
A patient reports a headache, nasal congestion, and fever for the past three days. A nurse examines the patient's nose and sinus areas thoroughly. What findings would suggest that the patient has sinusitis? Select all that apply.
Clinical findings that indicate sinusitis include hyperemic and edematous mucosa, tenderness over the involved sinuses, and enlarged turbinates. The inflammation results in increased blood supply to the affected area, which leads to hyperemic and edematous mucosa. Due to the inflammation, there may be tenderness over the involved frontal and/or maxillary sinuses. The turbinates may enlarge due to congestion. Clear nasal discharge is not a sign of sinusitis. Patients with sinusitis usually have a purulent nasal discharge. Nosebleed is not a manifestation of sinusitis.
A patient with a nasal fracture is scheduled for a fracture reduction surgery in two weeks. What preoperative instructions should a nurse give to the patient? Select all that apply.
The nurse should instruct the patient to avoid intake of NSAIDs at least two weeks before the surgery to reduce the risk of bleeding. The patient should avoid smoking because smoking cessation promotes better wound healing. Avoiding exercise is a postoperative instruction and helps to prevent bleeding. Applying ice is a postoperative instruction to decrease swelling. Alcohol tends to increase swelling and should be avoided after the operation.
When educating a patient about managing sinusitis without pharmacologic interventions, which instructions should the nurse include? Select all that apply.
In the case of sinusitis, steam inhalation helps to promote drainage of secretions. Sleeping with the head elevated helps to drain the sinuses and reduce congestion. Smoke is an irritant and will worsen the symptoms of sinusitis. Adequate fluid intake will decrease the symptoms of sinusitis. Applying a cold compress on the cheeks is not recommended because this worsens the symptoms. A hot compress on the cheeks will help.
A patient with allergic rhinitis has been advised to use beclomethasone nasal spray to relieve the symptoms. What instructions should be given to this patient about the use of corticosteroid nasal spray? Select all that apply.
The corticosteroid nasal spray should be used on a regular basis to obtain maximum benefit. In this case, the patient should take nasal spray twice daily, as ordered. Use of the nasal spray should be discontinued if nasal infection occurs because it may suppress the immune system and aggravate the infection. Nasal passages should be cleared before using the spray to ensure that the medicine reaches the target area. The spray should not be used on an as-needed basis because overuse can worsen symptoms. The spray does not need to be started two weeks before the pollen season begins.
A patient comes to the emergency department (ED) complaining of recurrent epistaxis. The nurse knows that recurrent episodes of epistaxis can be caused by which of these problems? Select all that apply.
Nasal tumors, some anatomic malformations of the nose, foreign bodies inserted into the nose, and facial trauma can result in epistaxis. Using nasal decongestant sprays too frequently can also cause nose bleeds. Fever of unknown origin does not cause nasal bleeding. Low humidity, not high humidity, also can increase one's risk of epistaxis.
The 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.
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 is suctioning the tracheostomy tube of a patient. Which action by the nurse would be a priority ?
The nurse should supply oxygen for 30 seconds after suctioning and before starting the next suction. Suctioning should be performed for a short period, such as for 10 seconds, but not for five minutes. Suctioning should be discontinued if the heart rate falls from the baseline by 20 beats/minute. The suction pressure of 90 to 100 mm Hg is not sufficient for effective suctioning; therefore, the nurse should adjust the suction pressure to 120 to 150 mm Hg.
A nurse is suctioning the airway of a patient with a tracheostomy tube in place. While suctioning, the nurse notices that the heart rate of the patient drops from 80 to 60 beats/minute. What nursing intervention is most appropriate in this case?
A drop in the heart rate during suctioning indicates hypoxia. If the heart rate drops or increases by 20 beats per minute while suctioning the airway through a tracheostomy tube, suctioning should be stopped immediately. No intermittent or continuous suction should be applied, because it may lead to hypoxia. The suction catheter should be rotated while applying suction.
When caring for a patient who is three hours postoperative laryngectomy, what is the nurse's highest priority assessment?
Remember the airway, breathing, and circulation (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 been on a mechanical ventilator with an endotracheal tube for three weeks, and the primary health care provider wants to perform a tracheostomy. Which benefits are associated with tracheostomy in a patient? Select all that apply.
A tracheostomy is a surgically created opening to provide ventilation. It facilitates the removal of secretions, bypasses an airway obstruction, and provides long-term mechanical ventilation. Subcutaneous crepitus and narrowing of the trachea are complications associated with tracheostomy.
Which action by the student nurse when providing tracheostomy care to a patient indicates a need for further teaching?
Dried secretions from the stoma are removed using gauze that is soaked in sterile water or normal saline, but not in alcohol. Hand hygiene reduces the risk of infection to the patient. Tracheostomy care is performed by positioning the patient in a semi-Fowler's position. The nurse can suction as needed when the patient is unable to cough up the thick and hard secretions.
Which nursing intervention should the nurse include in the teaching plan for a patient with acute pharyngitis whose laboratory reports indicate the presence of a candidiasis infection?
Gargling with warm salt water helps in relieving swelling and discomfort in the throat. The patient may have aspirin or ibuprofen if he or she reports pain. Lemon is a citrus fruit and would result in more throat irritation. Warm and cool fluids are appropriate for patients with pharyngitis related to candida.
The nurse is performing a tracheostomy dressing change for a patient. Which action is most appropriate when changing the dressing?
A dressing designed to be used for a tracheostomy or with an unlined gauze should be used to reduce the risk of complications in the patient. The nurse should not cut the gauze before using it because the patient may inhale the threads. The dressing should be changed frequently, not once every two days. The nurse should wash his or her hands before and after applying the dressing, following effective infection control measures.
A nurse is cleaning the inner cannula of a patient who is using a tracheostomy tube. Which order should the nurse follow while cleaning the cannula?
While cleaning the inner cannula, the nurse should immerse the cannula in a sterile cleansing solution first. Then, the outer and inner sides of the cannula should be cleaned using a tube brush or pipe cleaner. The cannula should then be rinsed in a sterile saline solution and dried. The nurse should then insert the cleaned inner cannula into the outer cannula with its curved part downward before locking it in place.
The nurse is observing a new graduate nurse during suctioning of a tracheostomy patient. Which action by the graduate nurse would require intervention?
Suction is not applied while inserting the catheter; intermittent suction is applied as the catheter is being withdrawn. Preoxygenation is also required before suctioning, and suction time should be limited to 10 seconds or less. A patient is at risk for hypoxemia after suctioning. Therefore it is imperative to monitor the patient's oxygen status before, during, and after suctioning. The catheter should be rotated during withdrawal
Which assessment procedure is used to clinically assess for a swallowing dysfunction? Select all that apply.
Assessment of a patient's ability to swallow is performed using videofluoroscopy, fiberoptic endoscopy, and by a speech physiotherapist. A charge nurse and chest physiotherapist do not assess for swallowing dysfunction.
Which information should a nurse provide to the family of a patient who is using an endotracheal tube in an emergency department?
Patients requiring mechanical ventilation are initially managed with an endotracheal tube. The tube does not allow for much movement, and patients who have endotracheal tubes cannot eat. Endotracheal intubation is generally not performed to aspirate the trachea of a patient.
What statement made by the student nurse indicates that education regarding tracheostomy tubes has been effective?
Patients who use a tracheostomy tube may be able to learn to speak with the tube in place. Patients who have endotracheal tubes are not able to speak because no air bypasses the vocal chords completely. Patients with tracheostomy tubes can eat, will experience less discomfort, and will have less risk of damage to the vocal cords than patients with endotracheal tubes
The nurse is completing tracheostomy care. Which of these is the best method for ensuring the fit of tracheostomy ties?
When securing tracheostomy ties, place two fingers underneath the ties to ensure that they are not too tight around the patient's neck. The respiratory therapist may not be trained in changing the ties, or may not check them accurately. The patient may not be able to identify if the ties are too tight. One finger beneath the tie is too tight.
The nurse is caring for a child and observes widening of the nostrils, restlessness, and auscultates expiratory wheezes. What is the priority action by the nurse?
Flaring or widening nostrils, wheezing or whistling sounds during expiration, and restlessness indicate airway obstruction in the patient. The priority intervention is to maintain a patent airway until further treatment can be initiated. An IV line can be inserted but is not the priority action at this time. ABC's (airway, breathing, and circulation) are the priority in order to prevent a poor outcome. Food and fluid should be withheld until the airway is unobstructed to prevent aspiration. The child should not lie flat at this time, and the head of the bed should be elevated.
A patient has an infection caused by β-hemolytic streptococci. What condition does the nurse correlate with this bacterial infection?
A peritonsillar abscess is a complication of bacterial acute pharyngitis that is most often caused by β-hemolytic streptococci. Sinusitis is caused by rhinovirus and coronavirus and is characterized by inflammation of the sinuses. Fungal pharyngitis is a fungal infection caused by Candida albicans. Acute viral rhinitis is caused by a virus, but not by β-hemolytic streptococci.
Which tube has openings on the surface of the cannula to permit airflow?
A fenestrated tube has openings on the surface of the outer cannula that permit air to flow over the vocal cords. Speaking tracheostomy tubes, tracheostomy tubes with foam-filled cuffs, and tracheostomy tubes with cuffs and pilot balloons do not have openings on the surface of the cannula.
Routine tracheostomy care is on the treatment plan for a patient that has a fenestrated tracheostomy tube. What should be the order of actions performed by the nurse for proper tracheostomy care?
During routine tracheostomy care, the required sterile equipment should be assembled near the patient's bed. Hands should be washed before the procedure. Gloves and goggles are to be worn. At first, the inner cannula is unlocked and cleaned in sterile water or saline solution. The inner cannula should be replaced after cleaning. The stoma is then cleaned with sterile gauze to remove dried secretions. Retention sutures, if present, should be properly positioned and secured. Subsequently, tracheostomy ties are changed.
The nurse is caring for the patient with acute pharyngitis. Which action by the nurse is most appropriate?
Offering a drink of water is correct because cool, bland liquids, such as water, will not irritate the pharynx. Citrus juices often irritate the pharynx, making it painful. Drinking warm or cold liquid is recommended, but consuming hot tea will irritate the pharynx and cause pain. Gargling with warm salt water can alleviate the symptoms of acute pharyngitis, but there are no recommendations to use hydrogen peroxide to alleviate the symptoms.
The patient with a tracheostomy is receiving humidified air. Which rationale(s) for the patient's use of humidification are correct? Select all that apply.
Preventing formation of mucous plugs, warming secretions, and moisturizing secretions are correct because humidification is essential to prevent retention of tenacious secretions and formation of mucous plugs. Humidified air compensates for the loss of the upper airway to warm and moisturize secretions. Preventing lower airway heat loss is incorrect because humidified air compensates for the loss of the upper airway, not the lower airway, to warm and moisturize secretions. Additionally, it actively warms and therefore does not prevent heat loss.
The nurse is planning to deflate the tracheostomy cuff of a patient. Which task is least helpful in preventing secretions from being aspirated during deflation?
Deflating the cuff during inspiration would be least helpful in preventing aspiration because the tracheostomy cuff should be deflated during the patient's expiration and exhaled gas helps propel secretions into the mouth. Suctioning the tracheostomy tube and then the mouth are important steps in preventing secretions from being aspirated during cuff deflation. Having the patient cough and therefore clear the lower airway before cuff deflation minimizes risk of aspiration. Suctioning the tracheostomy tube and then the mouth are important steps in preventing secretions from being aspirated during cuff deflation.
Which task can the registered nurse (RN) delegate to an a properly trained unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy?
If the UAP have been trained in correct technique, UAP may suction the patient's oropharynx. Assessing the need for suctioning should be performed by an RN or licensed practical nurse, whereas swallowing assessment and the maintenance of cuff inflation pressure should be performed solely by the RN.
The nurse is planning to perform tracheostomy care on a patient. In what order does the nurse perform the procedure? Place options in order of importance.
The procedure must first be explained to the patient. The proper equipment can be placed at the bedside. If the equipment is placed first, the patient might be frightened. Position the patient in semi-Fowler's position. Next put on goggles and clean gloves and auscultate chest sounds before beginning the procedure to determine if suctioning is needed. Next change the tracheostomy cannula. After the tracheostomy has been changed and dressing applied, tracheostomy ties can be changed.
The nurse is providing tracheostomy care to a patient. Which nursing actions should be a priority while providing this care? Select all that apply.
Before applying suction, the nurse should auscultate for lung sounds to check for the presence of rhonchi or coarse crackles; if they are present, the nurse can encourage the patient to cough up secretions. The nurse should remove the soiled dressing while providing tracheostomy care. Before starting the procedure, the nurse should explain the procedure to the patient to reduce anxiety. Tracheostomy care is provided as many times as needed per day. The patient should be in a semi-Fowler's position during tracheostomy care.
The patient with a tracheostomy needs suctioning. These interventions are included in the plan for suctioning. In what order should the nurse perform these actions?
If suctioning is indicated, the needed supplies are gathered and the suction source checked before washing hands and putting on eye protection. Sterile technique is used to open the package and prepare the equipment. Then one hand is designated as contaminated to facilitate sterile suctioning with the other hand. The patient may be preoxygenated before the catheter is inserted gently without suction to minimize the amount of oxygen removed from the lungs. Then suction is applied intermittently while withdrawing the catheter in a rotating manner for 10 seconds. If another suction pass is needed, the catheter is rinsed with sterile water between passes until airway is clear or three passes have occurred (the patient will rest after three passes before additional suctioning). After suctioning the oropharynx, the lung sounds will be assessed and the time, amount, character of secretions, and response to suctioning will be recorded.
A nurse is caring for a patient who has undergone laryngectomy. Upon suctioning the tracheostomy tube, the nurse notices a slight thickening of the secretions. Which measures should the nurse take to prevent thickening of secretions? Select all that apply.
Maintaining adequate hydration through an intravenous or enteral route and humidifying the inspired gases prevents drying and thickening of secretions. This allows easy suction of secretions. Changing the patient's position helps to relieve dyspnea in the patient. Changing the tracheostomy tube does not help, because the secretions are too copious to be removed. A normal saline bolus is not recommended, because it may cause infection.
A patient with bacterial pharyngitis is prescribed penicillin. The nurse knows what about this drug? Select all that apply.
Oral penicillin needs to be taken several times a day for 10 days to prevent rheumatic fever, which is a sequela to the infection. Patients must take the drug orally for 24 to 48 hours before they are considered noncontagious. It has no effect on fever.
A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when the patient coughs and expels the tracheostomy tube. How should the nurse respond?
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 nurse would not suction the tracheostomy opening at this point. If the patient is in respiratory distress, the nurse will use an Ambu bag and mask to ventilate the patient temporarily. The tracheostomy is an open surgical wound that has not had time to mature into a stoma.
A patient with a history of tonsillitis complains of difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse?
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.
Which actions by a patient will relieve dry mouth? Select all that apply.
Sucking on ice chips, chewing sugarless gum, and sucking on sugarless candy will help in managing dry mouth in the patient. Eating bland foods will aid in swallowing and reduce irritation. Rinsing the mouth with salt water helps to heal oral mucositis and relieve irritation.
Which type of foods should be given to a patient who has oral mucositis?
A patient with oral mucositis will have irritation and ulceration in the mouth. Bland and soft foods, such as fruit and vegetable juices, should be given to the patient to avoid irritation. Potato chips are hard to chew and can further irritate the oral mucosa. Pico de gallo and chicken fried steak may be spicy and can irritate the oral mucosa.
What are the symptoms of laryngeal cancer? Select all that apply.
Leukoplakia (white patches on the lining of the cheeks of the mouth), hoarseness, and difficulty swallowing are symptoms of laryngeal cancer. A scratchy throat is a symptom of acute pharyngitis. Discolored nasal drainage is a symptom of sinusitis.
Which condition is suspected in a patient who is exposed to sun and asbestos?
Exposure to sun and asbestos are risk factors for head and neck cancer. Rhinitis is suspected when the patient is exposed to animal dander and house molds. Sinusitis is suspected when the patient has inflammation of the mucosa that blocks the opening to the sinuses. Influenza is suspected when the patient is exposed to an influenza virus.
What are the clinical manifestations of oral mucositis? Select all that apply.
Oral mucositis is a common complication from radiation therapy. Pain, irritation, and ulceration are clinical manifestations of oral mucositis. Oral mucositis is not characterized by dental caries. Nasal decongestion is the clinical manifestation of sinusitis
The nurse is providing education about head and neck cancer at a community fair. What does the nurse list as the main cause of head and neck cancers?
Tobacco and smokeless tobacco cause 85% of head and neck cancer. Alcohol can be a cause of oral, pharyngeal, laryngeal, and esophageal cancers, but it is not the main cause. Infections and trauma are unrelated to head and neck cancer.
Which is a clinical manifestation of an early sign of laryngeal cancer?
Hoarseness for more than two weeks is an early sign of laryngeal cancer. Discolored purulent nasal drainage and tenderness at the ethmoidal sinuses are signs of acute sinusitis. Rhinorrhea, a condition where the nasal cavity is filled with mucous fluid, is a sign for influenza.
What are side effects associated with radiation therapy? Select all that apply
Fatigue, dry mouth, and oral mucositis are side effects of radiation therapy. Constipation is a side effect associated with antihistamines. Nasal irritation is a side effect associated with the use of anticholinergics and antihistamines.
The patient has a suspected lesion in the throat. Which tool is the nurse most likely to prepare at the bedside for the physician to use to further examine the patient?
The laryngoscope is the best tool to visualize the airway at the bedside. A stethoscope is used for listening to chest sounds. An ultrasound may be used to examine the throat, but first the health care provider will use the laryngoscope. A PET scan is a radiologic exam that is not completed at the bedside and does not visualize the airway.
The nurse is reading a pathologic report on a patient who has esophageal cancer. Which letter informs the nurse that the cancer has spread to another part of the body?
The "M" in TNM staging to evaluate the extent of cancer stands for metastasis, which indicates the spread of cancer beyond its site of origin. "T" stands for tumor, which is the site of origin. "N" stands for lymph node involvement. "D" is not a letter used in TNM staging.
A patient with a radical neck dissection is refusing enteral feeding. Which factor should the nurse monitor in this patient?
A patient who has a radical neck dissection will have difficulty eating; enteral feeding is used to provide the required nutrients. If the patient refuses to take enteral feeding, he or she may have an inadequate supply of nutrients, which will result in weight loss. The nurse should closely monitor weight loss in any patient who refuses enteral feeding. Pulse rate, blood pressure, and respiratory rate are not affected if the patient refuses to take enteral feeding.
The nurse teaches a patient who is experiencing oral mucositis due to radiation therapy about care measures. During a follow-up visit, the patient reports severe mouth irritation. Which action of the patient indicates the need for further teaching?
Because the oral mucosa is affected during radiation therapy, the patient will experience dry mouth and oral mucositis. Commercial mouthwashes can irritate the mouth severely, and the nurse should instruct the patient to avoid them. A patient who experiences oral mucositis will have pain; sucking ice chips can cause numbness and relieve the pain. Rinsing the mouth with salt and baking soda four to six times a day will promote healing. Equal proportions of antacid, diphenhydramine, and topical lidocaine reduces severe irritation.
What are the changes in a patient after undergoing a total laryngectomy? Select all that apply.
A total laryngectomy is the removal of the larynx. It is associated with loss of speech, taste, and smell. A total laryngectomy does not disturb the vision or physical mobility in the patient.
A nurse is teaching a patient how to manage fatigue induced by radiation therapy. What statement by the patient indicates a correct understanding of the lesson?
"Because I have the most energy in the morning, I will plan my errands during this time" indicates that the patient understands the importance of doing activities that are most important to them and to rest during periods of low energy. Fatigue is a common side effect of radiation therapy and usually begins a few weeks into therapy. "I will walk three to four hours every day to increase my level of energy" indicates that the patient does not understand that scheduling activities for a period of three to four hours is excessive and does not allow time for adequate rest periods. It is important that patients suffering from radiation-induced fatigue identify support systems as a means of assistance. Avoiding requests for help would be counter to this teaching. Continuous engagement in activity would not provide periods of much needed rest for a patient who is fatigued from radiation therapy.
Which technique of voice restoration in a laryngectomy involves creation of a fistula between the esophagus and trachea in a patient?
Transesophageal puncture is a method of voice restoration in patients who have undergone laryngectomy. This procedure involves the creation of a fistula between the esophagus and trachea. Esophageal speech is a technique in which the patient inhales air, traps it in the esophagus, and releases it to create sound. Intraoral electrolarynx and neck type electrolarynx are two types of electrolarynx devices that create speech by using sound waves.
Why is a nasogastric tube inserted during surgery?
Nasogastric tube intubation is performed during surgery to remove the stomach contents for the first 24 to 48 hours because of the reduction or absence of peristalsis. A tracheostomy tube or an endotracheal tube is used to provide mechanical ventilation. A nasogastric tube is also used to provide food to the patients via the nose; keep in mind that feedings are not given during surgery.
Which surgery is associated with the partial removal of one vocal cord?
Cordectomy is the partial removal of one vocal cord. Hemilaryngectomy involves the removal of one side of the larynx. Supraglottic laryngectomy is the removal of the epiglottis and false vocal cords. Supracricoid laryngectomy is the removal of the entire supraglottis, false and true vocal cords, and thyroid cartilage, including the paraglottic and preepiglottic spaces.
Which nursing interventions should the nurse conduct while providing home care to a patient with a stoma after a tracheostomy? Select all that apply.
The stoma should be covered with a soft cloth to prevent infection, and the patient's water intake should be increased to prevent dryness, especially in dry weather. Because patients who have undergone a cordectomy lose the ability to taste and smell, the nurse should serve colorful food to the patient in an attempt to generate interest in food. The nurse should clean the area around the stoma at least daily and should not let the patient take a bath or shower without wearing a plastic collar, which prevents entry of water into the stoma
The nurse is providing instructions on safety measures to a patient who has a laryngectomy stoma. Which action of the patient prevents crusting of the laryngectomy stoma?
A laryngectomy stoma is a hole made in the neck during surgery that the patient can breathe through. Applying a nasal wash spray around the stoma such as Alkalol every one to two hours will keep the stoma moist and prevent it from crusting. Covering the stoma while coughing or during activities like shaving or applying makeup prevents the entry of foreign particles. Washing the area around the stoma with a moist cloth will clean any secretions. Wearing a plastic cloth while taking a shower will prevent the entry of water into the stoma.
The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect?
Because 50% of patients with head and neck cancer are malnourished before treatment begins, many patients need enteral feeding via a gastrostomy tube because the effects of treatment make it difficult to take in enough nutrients orally, whether surgery, chemotherapy, or radiation are 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.
Which risk factors can result in head and neck cancer in a patient? Select all that apply.
HPV infection, poor oral hygiene, and exposure to asbestos are risk factors that can result in head and neck cancer. Exposure to animal dander is a risk factor that results in allergic rhinitis in the patient. Exposure to coxsackie viruses can cause acute viral rhinitis in the patient.
The laryngoscopy report of a patient indicates the presence of a cancerous mass over the vocal cords. The patient is to be treated with radiation therapy. How can a nurse help the patient cope with the side effects of radiation therapy? Select all that apply.
Dry mouth is the most common side effect of radiation therapy. The nurse should instruct the patient to increase fluid intake because hydration will help the patient to relieve symptoms. Due to radiation therapy, the patient's saliva decreases in volume and becomes thick. Pilocarpine hydrochloride is helpful in increasing saliva production. Soft and bland foods cause less irritation to the oral mucosa and should be encouraged if the patient has oral mucositis. Alcohol cessation should be encouraged following the diagnosis of cancer to avoid complications. Artificial saliva also helps in keeping the mouth hydrated in xerostomia.
What is the most frequent and annoying side effect that typically begins a few weeks after initiating radiation therapy in a patient with head and neck cancer?
Xerostomia is defined as dry mouth resulting from reduced or absent saliva flow. It is the most frequent and annoying side effect of radiation therapy and typically begins few weeks after initiating radiation therapy in a patient with head and neck cancer. Depression is not specifically associated with radiation therapy. Frozen shoulder is caused by removal of or damage to the spinal accessory nerve and sternocleidomastoid muscles. Copious blood-tinged secretions may be seen in a patient who has undergone surgical therapy.
The nurse is caring for a patient who has undergone neck surgery. Which type of food should the nurse avoid while feeding the patient orally?
Thin, watery fluids are difficult to swallow and can lead to aspiration in the patient; these foods should be avoided. Bland foods are tolerable and provide less irritation or inflammation if accidentally aspirated. Pureed foods and thickened liquids should be given to the patient because they can be swallowed easily.
A nurse caring for a patient post-laryngectomy begins to suction the patient. The nurse notes that the mucous is blood-tinged. What is the most appropriate nursing action?
Following a laryngectomy, it is important to maintain a patent airway, which can be done by regularly suctioning through a tracheostomy. The nurse should continue to monitor the patient. Initially the mucus will be blood tinged, so there is no need to notify the surgeon. A saline bolus should not be given through tracheostomy because this can block the airway and cause asphyxia. A change of position is not necessary.
Radiation therapy is planned for a patient with head and neck cancer. Which medication will the nurse administer to the patient before initiating the therapy?
Because radiation therapy can cause dry mouth, the nurse should administer pilocarpine hydrochloride medication to increase the production of saliva. Zanamivir is used in the treatment of influenza. Olopatadine is an antihistamine used in the treatment of allergic rhinitis. Pseudoephedrine is an oral decongestant used in medications for sinusitis.
The nursing instructor is evaluating a student nurse's teaching plan about preventive measures for head and neck cancer in patients. Which statement of the student nurse does the nursing instructor correct?
Both chewing and smoking tobacco cause head or neck cancer; chewing tobacco should not be recommended. Cigarettes should generally be avoided. Alcoholics and people with poor oral hygiene are at greater risk of developing head and neck cancer.
The instructor nurse is teaching a student nurse about the measures to be followed for a patient who has received radiation therapy. Which statement of the student nurse indicates effective learning?
Patients undergoing radiation therapy should use only prescribed lotions. Patients who are on radiation therapy should increase their mobility and do regular exercises to boost up their energy levels. Lotion should not be applied within two hours of treatment. The patient should refrain from rubbing the area immediately after the therapy because the irradiated skin is very sensitive and prone to injury.
The nurse assesses a patient with intrinsic laryngeal cancer. Which finding is most characteristic of this type of cancer?
Hoarseness occurs early in the course of most intrinsic (vocal cord) laryngeal cancers. The tumor prevents accurate approximation of the vocal cords during phonation, resulting in mild hoarseness. Chronic foul breath, difficulty swallowing, and a nagging dry, nonproductive cough may also be seen with laryngeal cancer but are not as common or consistent as hoarseness.
Which nonsurgical method is best to restore speech in a patient who cannot achieve sound conduction on the skin?
An intraoral electrolarynx is a device used to restore speech in patients who have impaired sound conduction on the skin. The use of esophageal speech helps patients develop a few speaking skills, but not fluent speech. A neck type electrolarynx is an intraoral device that is placed on the chin, neck, or cheek to articulate sound. This method involves the use of skin; thus, this device cannot be used in patients with impaired sound conduction on the skin. Transesophageal puncture is a surgical procedure in which a fistula is created between the trachea and esophagus.
A student nurse is providing postoperative care to a patient who has undergone a laryngectomy and has a tracheostomy tube. Which action of the student nurse indicates the need for further training?
Infusing the normal saline solution into the tracheostomy tube can cause hypoxia and endothelial cell damage. Encouraging the patient to cough frequently removes the sputum from the lungs. Positioning the patient in a semi-Fowler's position decreases tension on the sutures and prevents edema and aspiration in the patient. Suctioning when coughing to remove secretions is a sign of good tracheostomy care.
The registered nurse has completed the training of a licensed practical nurse about his or her responsibilities. Which action of the licensed practical nurse needs correction?
A registered nurse, but not a licensed practical nurse, can assess the patient's risk of aspiration. A licensed practical nurse can perform suctioning of the tracheostomy tube, provide tracheostomy care or change the tracheostomy dressing, and evaluate the patient's health after suctioning.
Which drug is used as a targeted therapy for head and neck cancer?
Cetuximab is an anticancer agent used as a targeted therapy in head and neck cancer after standard chemotherapy. Olopatadine is effective in the treatment of rhinitis. Mometasone is a corticosteroid used in the treatment of sinusitis and allergic rhinitis. Ipratropium bromide is an anticholinergic used to treat rhinitis.
A patient with head and neck cancer has undergone a cordectomy. Which complication is associated with this procedure?
Cordectomy is surgical removal of the vocal cords, which causes impaired verbal communication. The patient may have anxiety due to lack of knowledge regarding a surgical procedure; anxiety is not specifically associated with cordectomy. Acute pain is related to tissue injury during surgery. The presence of an artificial airway and the accumulation of mucus in the airways increases risk of aspiration; these complications are not associated with cordectomy.
A student nurse is providing food orally to a patient who refuses enteral feeding. Which action made by the student nurse indicates the need for correction?
Enteral feeding is suggested to a patient who has undergone radical neck dissection. If the patient refuses food by enteral feeding, the nurse should provide the food orally. Positioning the patient in a supine position can result in aspiration; placing the patient in a high Fowler's position or elevating the bed is recommended. Adding dry milk to the food will supplement the caloric intake of the patient. Adding thickeners to the food can make the food difficult to swallow. Administering antiemetics before meals or snacks will help reduce nausea.
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