Upper Respiratory Chapter 27

Front 1

The nurse teaches a 66-year-old man with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which statement, if made by the patient, indicates further teaching is required?

 “I should avoid using ibuprofen (Motrin) for pain and discomfort.”  “It is important for me to take my blood pressure medication every day.”  “I will sit down and pinch the tip of my nose for at least 10 to 15 minutes.”  “If I get a nosebleed, I will lie down flat and raise my feet above my heart.”

Back 1

4              A simple measure to control epistaxis (or a nosebleed) is for the patient to remain quiet in a sitting position. Another measure would be to apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes. Aspirin or 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.

Front 2

The nurse teaches a 20-year-old female patient who is prescribed budesonide (Rhinocort) intranasal spray for seasonal allergic rhinitis. The nurse determines that medication teaching is successful if the patient makes which statement?

 “My liver function will be checked with blood tests every 2 to 3 months.”  “The medication will decrease the congestion within 3 to 5 minutes after use.”  “I may develop a serious infection because the medication reduces my immunity.”  “I will use the medication every day of the season whether I have symptoms or not.”

Back 2

4                Budesonide should be started 2 weeks before pollen season starts and used on a regular basis, and 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.

Front 3

The nurse in the occupational health clinic prepares to administer the influenza vaccine by nasal spray to a 35-year-old female employee. Which question should the nurse ask before administration of this vaccine?

 “Are you allergic to chicken?”  “Could you be pregnant now?”  “Did you ever have influenza?”  “Have you ever had hepatitis B?”

Back 3

2              The live attenuated influenza vaccine (LAIV) is given by nasal spray and approved for healthy people age 2 years 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.

Front 4

A 62-year-old male 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?

 Level of consciousness  Quality of breath sounds  Presence of the gag reflex  Tracheostomy cuff pressure

Back 4

2                    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.

Front 5

All of the following care tasks are needed by a patient admitted for joint replacement surgery who has had a permanent tracheostomy for over 10 years. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

 Suction the tracheostomy.  Check stoma site for skin breakdown.  Complete tracheostomy care using sterile technique.  Provide oral care with a toothbrush and tonsil suction tube.

Back 5

4                    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.

Front 6

The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. What should the nurse do first?

 Test the drainage for the presence of glucose.  Suction the nose to maintain airway clearance.  Document the findings and continue monitoring.  Apply a drip pad and reassure the patient this is normal.

Back 6

1              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.

Front 7

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)?

 Tilt patient's head backwards.  Apply ice compresses to the nose.  Tilt head forward while lying down.  Pinch the entire soft lower portion of the nose.  Partially insert a small gauze pad into the bleeding nostril.

Back 7

2, 4            First aid measures to control epistaxis include placing the patient in a sitting position, leaning forward. 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.

Front 8

When caring for a patient who is 3 hours postoperative laryngectomy, what is the nurse's highest priorityassessment?

 Patient comfort  Airway patency  Incisional drainage  Blood pressure and heart rate

Back 8

2          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.

Front 9

When initially teaching a patient the supraglottic swallow following a radical neck dissection, with which food or fluid should the nurse begin?

 Cola  Applesauce  French fries  White grape juice

Back 9

1             When learning the supraglottic swallow, it may be helpful to start with carbonated beverages because the effervescence provides clues about the liquid's position. Thin, watery fluids should be avoided because they are difficult to swallow and increase the risk of aspiration. Nonpourable pureed foods, such as applesauce, would decrease the risk of aspiration, but carbonated beverages are the better choice with which to start.

Front 10

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?

 Hypersensitivity to eggs  Age greater than 80 years  History of upper respiratory infections  Chronic obstructive pulmonary disease (COPD)

Back 10

1               Although current vaccines are highly purified, and 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.

Front 11

Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy?

 Assessing the need for suctioning  Suctioning the patient's oropharynx  Assessing the patient's swallowing ability  Maintaining appropriate cuff inflation pressure

Back 11

2              Providing the individual has 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.3

Front 12

What is the priority nursing assessment in the care of a patient who has a tracheostomy?

 Electrolyte levels and daily weights  Assessment of speech and swallowing  Respiratory rate and oxygen saturation  Pain assessment and assessment of mobility

Back 12

3          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.

Front 13

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when he coughs and expels the tracheostomy tube. How should the nurse respond?

 Suction the tracheostomy opening.  Maintain the airway with a sterile hemostat.  Use an Ambu bag and mask to ventilate the patient.  Insert the tracheostomy tube obturator into the stoma.

Back 13

2               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.

Front 14

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?

 Apply an external splint to the nose.  Insert plastic nasal implant surgically.  Humidify the air for mouth breathing.  Maintain surgical packing in the nose.

Back 14

4              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.

Front 15

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)?

 Cover the nose when coughing.  Obtain an influenza vaccination.  Stay at home when symptomatic.  Drink non-caffeinated fluids daily.  Obtain antibiotic therapy promptly.

Back 15

1, 2, 3                  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.

Front 16

The patient seeks relief from the symptoms of an upper respiratory infection (URI) that has lasted for 5 days. Which patient assessment should the nurse use to help determine if the URI has developed into acute sinusitis?

 Coughing  Fever, chills  Dust allergy  Maxillary pain

Back 16

4              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.

Front 17

The patient has been diagnosed with head and neck cancer. Along with the treatment for the cancer, what other treatment should the nurse expect?

 Nasal packing  Epistaxis balloon  Gastrostomy tube  Peripheral skin care

Back 17

3                  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 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.

Front 18

A patient with a history of tonsillitis complains of difficulty breathing. Which patient assessment data warrants emergency interventions by the nurse?

 Bilateral erythema of especially large tonsils  Temperature 102.2° F, diaphoresis, and chills  Contraction of neck muscles during inspiration  β-hemolytic streptococcus in the throat culture

Back 18

3                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.

Front 19

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?

 Electromyograph  Intraoral electrolarynx  Neck type electrolarynx  Transesophageal puncture

Back 19

4                  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, 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.

Front 20

a deflection of the normally straight nasal septum that is most commonly caused by trauma to the nose or congenital disproportion?

Back 20

deviated septum

Front 21

If a nasal fracture is present, nursing responsibilities include?

Back 21

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

Front 22

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?

Back 22

rhinoplasty

Front 23

Epistaxis has a wide variety of causes. To treat epistaxis, simple measures, including direct pressure with the patient upright, should be tried first.  o    If bleeding does not stop?

Back 23

 application of a vasoconstrictive agent, packing, or cauterization may be warranted.

Front 24

critical nursing responsibility if the patient has nasal packing?

Back 24

monitoring resp status

Front 25

reaction of the nasal mucosa to a specific allergen?

Back 25

allergic rhinitis

Front 26

Seasonal rhinitis is caused by?

Back 26

allergies to pollens from trees, flowers, or grasses

Front 27

Perennial rhinitis occurs from?

Back 27

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

Front 28

The most important step in managing allergic rhinitis involves 

Back 28

identifying and avoiding triggers of allergic reactions.

Front 29

also known as common cold, is an infection of the upper respiratory tract that can be caused by more than 200 different viruses?

Back 29

acute viral rhinitis

Front 30

In contrast to acute viral rhinitis, the onset of influenza is typically?

Back 30

abrupt with systemic symptoms of chills, fever, anorexia, malaise, and generalized myalgia often accompanied by a headache, cough, rhinorrhea, and sore throat.

Front 31

Antivirals such as zanamivir (Relenza) and oseltamivir (Tamiflu) are used to prevent and treat?

Back 31

influenza A & B

Front 32

To combat the likelihood of developing influenza, there are two types of flu vaccines available: 

Back 32

inactivated and live, attenuated.

Front 33

You should advocate for the use of influenza vaccination in all patients greater than 

Back 33

6 months of age

Front 34

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?

Back 34

sinusitis

Front 35

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?

Back 35

chronic sinusitis

Front 36

    Nasal polyps can cause?

Back 36

obstruction and speech distortion, necessitating surgical removal

Front 37

an acute inflammation of the pharyngeal walls that may include the tonsils, palate, and uvula?

Back 37

acute pharyngitis

Front 38

Acute paryngitis symptoms?

Back 38

Symptoms range in severity from complaints of a “scratchy throat” to pain so severe that swallowing is difficult. Both viral and strep infections appear as a red and edematous pharynx, with or without patchy exudates, so appearance is not always diagnostic.

Front 39

The goals of nursing management for acute pharyngitis are?

Back 39

infection control, symptomatic relief, and prevention of secondary complications.

Front 40

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

Back 40

peritonsillar abcess

Front 41

Airway obstruction is a medical emergency. Interventions to reestablish a patent airway include the ?

Back 41

 obstructed airway (Heimlich) maneuver, cricothyroidotomy, endotracheal intubation, and tracheostomy.

Front 42

a surgically created opening in the trachea for the purpose of establishing an airway?

Back 42

A tracheostomy

Front 43

Polyps on the vocal cords develop as a result of 

Back 43

vocal abuse or irritation

Front 44

HEAD AND NECK CANCER

•    This category of tumors arises from the?

Back 44

 mucosal surfaces of the paranasal sinuses, oral cavity, or nasopharynx, oropharynx, or larynx