Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
AH Chapter 26
Upper Respiratory Proble,s
| Question | Answer |
|---|---|
| A pt is seen in the clinic for a nosebleed, which is controlled by placement of anterior nasal packing. During discharge teaching, the RN teaches the pt to: | Avoid vigorous nose blowing & strenuous activity 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 wouldnot teach the patient to insert more packing into a nose with packing already in-situ. |
| A pt w/allergic rhinitis reports severe nasal congestion; sneezing; and watery, itchy eyes & nose at various times of the year. What teaching will the RN give to control these symptoms? | Keep a diary of when allergic reaction occurs & what precipitates it. 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. |
| A pt is seen at the clinic w/fever, muscle aches, sore throat with yellowish exudate, and headache. The RN anticipates that the interpersonal management will include what? | 1.)Throat culture or rapid strep test 2.) Supportive care, incl cool, bland, liquids. 3.) Comprehensive health hx to determine possible cause Goals of nursing management: infection control, symptom relief, and prevention of secondary complications. No antbx till cause known. 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. |
| The best method for determining r/o aspiration in a pt with a tracheostomy is to | Consult speech therapy for a swallowing assessment Clinical assessment by a speech therapist, videofluoroscopy, or fiberoptic endoscopic evaluations of swallow are recommended. Patients should begin swallowing with thickened liquids. Ability to swallow should be assessed with the cuff deflated, because cuff inflation may interfere with swallowing ability |
| Which nursing action would be of HIGHEST PRIORITY when suctioning a pt w/a trach? | Assessing the pt's SpO2 before, during, and after suctioning Rationale: A patient with a tracheostomy is at risk for hypoxemia during and after suctioning. Pre-oxygenate patientswith 100% FIO2prior to suctioning. Monitor the patient’s O2status before, during, and after suctioning. |
| When planning health care teaching to prevent or detect early head & neck cancer, which pt's would be the priority to target? | 1.) 65yo man who has chewed most of his life 2.) 45 yo rancher who snuff's to stay awake at night 3.) 78yo lady drinking alc for past 15 years 4.) 22yo lady dx of HPV of cervix 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 papillomavirus (HPV) infection. |
| While in recovery, a pt w/a total laryngectomy is suctioned and has bloody mucus w/some clots. Which nursing interventions would apply? | 1.) Place pt in semi-fowlers 2.) Continue pt assessment, including O2 sat, RR, & breath sounds. 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. |
| Appropriate D/C teaching for a pt w/a permanent tracheostomy after a total larengectomy for cancer should include what? | 1.) Wash around stoma daily w/moist washcloth 2.) encourage participation in postlaryngectomy support group 3.) Provide pictures & hands on instruction for trach care All correct measures; NO swimming as form of exercise! 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. |
| A patient with a history of tonsillitis reports difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse? | 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. |
| 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? | Tilt head forward while sitting upright. 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. |
| 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? | 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. |
| 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? | 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. |
| 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? | “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. |
| When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse’s highest priority assessment? | 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. |
| 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)? | 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. |
| 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? | 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. |
| The nurse is caring for a patient with a tracheostomy. What is the priority nursing assessment for this patient? | Respiratory rate and oxygen saturation Rationale: The priority assessment in the care of a patient with a tracheostomy focuses on airway and breathing. |
| 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? | 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 nurse is reviewing the health history of a patient with laryngeal cancer. Which finding would the nurse expect? | 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 pt seeks relief of symptoms of a URI lasting for 5 days. Which pt assessment should the RN use to help determine if the URI has developed into acute sinusitis? | 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 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? | 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 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? | 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. |
| 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? | “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. |
| Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? | 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. |
| 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? | 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. |
| 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? | 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. |
| 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? | “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 patient to remain quiet in a sitting position. Also, apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes. Aspirin/ NSAIDs increase bleeding time and should be avoided. Elevated blood pressure makes epistaxis more difficult to control. The patient should continue with antihypertensive medications as prescribed. |
Created by:
dkorak