Main priority in the expected outcomes for clients with upper respiratory tract infection quizlet

1. Fever is a sign of infection, and crepitus is
air trapped in the layers of the skin.
2. Rales indicate fluid in the lung, and hives are
a skin reaction to a stimulus such as occurs
with an allergy to a specific substance.
**3. During an asthma attack, the muscles
surrounding the bronchioles constrict,
causing a narrowing of the bronchioles.
The lungs then respond with the
production of secretions that further
narrow the lumen. The resulting
symptoms include wheezing from air
passing through the narrow, clogged
spaces, and dyspnea.**
4. During an attack, the chest will be
expanded from air being trapped and not
being exhaled. A chest x-ray will reveal a
lowered diaphragm and hyperinflated
lungs.

TEST-TAKING HINT: The test taker must
have a basic knowledge of common medical
terms to answer this question. Dyspnea,
wheezing, and rales are common terms used
when describing respiratory function and
lung sounds. Crepitus and eupnea are not as
commonly used, but they are also terms
that describe respiratory processes and
problems.

1. The contributing factors to developing
sleep apnea are obesity, smoking, drinkingalcohol, and a short neck. In some
situations, modifying lifestyle will improve
sleep apnea.
2. Many clients need a continuous positive
airway pressure (CPAP) machine, which
continuously administers positive pressure
to assist sleep during the night.
3. When clients have sleep apnea, the buildup
of carbon dioxide causes the client to
arouse constantly from sleep to breathe.
This, in turn, causes the client to be sleepy
during the day.
**4. Drinking alcohol before sleep sedates
the client, causing the muscles to relax,
which, in turn, causes an obstruction of
the client's airway. Drinking alcohol
should be avoided even if the client
uses a CPAP machine.**

In order of priority: 5, 2, 3, 4, 1.
5. The most common cause of bucking
the ventilator is obstructed airway,
which could be secondary to secretions
in the airway, so assessing the client
would be most appropriate.
2. Clients in the ICU are constantly
monitored by pulse oximetry;
therefore, the nurse should determine
if the client has decreased oxygen
saturation and if so, the nurse should
start to "bag" the client. The client is
in respiratory distress.
3. The nurse should assess the client's
lung fields to determine if air
movement is occurring since the client
is in respiratory distress.
4. A complication of mechanical ventilation
is a pneumothorax, and the nurse should
assess for this since the client is in
respiratory distress.
1. The machine is alerting the nurse
there is a problem with the client;
since the client is in respiratory
distress, the client should be assessed
first. If the client were not in distress,
then the nurse should assess the
machine first to determine which
alarm is sounding.

4. Adverse eects o pseudoephedrine (Sudaed) are experienced primarily in the car-diovascular system and through sympathetic eects on the central nervous system (CNS). The most common CNS adverse eects include rest-lessness, dizziness, tension, anxiety, insomnia, and weakness. Common cardiovascular adverse eects include tachycardia, hypertension, palpita-tions, and arrhythmias. Constipation and diplopia are not adverse eects o pseudoephedrine. Tachycardia, not bradycardia, is an adverse eect o pseudoephedrine.

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Terms in this set (40)

D

(Feedback:
Handwashing remains the most effective preventive measure to reduce the transmission of organisms. Taking prescribed antibiotics, using warm salt-water gargles, and dressing warmly do not suppress transmission. Antibiotics are not prescribed for a cold.)

The nurse is providing patient teaching to a young mother who has brought her 3-month-old infant to the clinic for a well-baby checkup. What action should the nurse recommend to the woman to prevent the transmission of organisms to her infant during the cold season?

A) Take preventative antibiotics, as ordered.
B) Gargle with warm salt water regularly.
C) Dress herself and her infant warmly.
D) Wash her hands frequently.

D

(Feedback:
For a patient diagnosed with acute sinusitis, the nurse should instruct the patient that hot packs, increasing fluid intake, and elevating the head of the bed can promote drainage. Applying a mustard poultice will not promote sinus drainage. Postural drainage is used to remove bronchial secretions.)

A patient visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the patient to perform which of the following?

A) Apply a cold pack to the affected area.
B) Apply a mustard poultice to the forehead.
C) Perform postural drainage.
D) Increase fluid intake.

C

(Feedback:
Management of acute laryngitis includes resting the voice, avoiding irritants (including smoking), resting, and inhaling cool steam or an aerosol. Fluid intake should be increased. Warm clothes on the throat will not help relieve the symptoms of acute laryngitis.)

The nurse is creating a plan of care for a patient diagnosed with acute laryngitis. What intervention should be included in the patient's plan of care?

A) Place warm cloths on the patient's throat, as needed.
B) Have the patient inhale warm steam three times daily.
C) Encourage the patient to limit speech whenever possible.
D) Limit the patient's fluid intake to 1.5 L/day.

D

(Feedback:
If pressure to the midline septum does not stop the bleeding for epistaxis, additional treatment of silver nitrate application, Gelfoam, electrocautery, or vasoconstrictors may be used. Suction may be used to visualize the nasal septum, but it does not alleviate the bleeding. Irrigation with a hypertonic solution is not used to treat epistaxis.)

A patient comes to the ED and is admitted with epistaxis. Pressure has been applied to the patient's midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using what treatment to control the bleeding?

A) Irrigation with a hypertonic solution
B) Nasopharyngeal suction
C) Normal saline application
D) Silver nitrate application

C

(Feedback:
Each of the listed diagnoses is valid, but ineffective airway clearance is the priority nursing diagnosis for all conditions.)

The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis?

A) Anxiety related to diagnosis of cancer
B) Altered nutrition related to swallowing difficulties
C) Ineffective airway clearance related to airway alterations
D) Impaired verbal communication related to removal of the larynx

A

(Feedback:
The nurse stresses the importance of humidification at home and instructs the family to obtain and set up a humidification system before the patient returns home. Air-conditioning may be too cool and too drying for the patient. A water purification system or a radiant heating system is not necessary.)

The home care nurse is assessing the home environment of a patient who will be discharged from the hospital shortly after his laryngectomy. The nurse should inform the patient that he may need to arrange for the installation of which system in his home?

A) A humidification system
B) An air conditioning system
C) A water purification system
D) A radiant heating system

A

(Feedback:
Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.)

The nurse is caring for a patient whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer?

A) Hoarseness
B) Dyspnea
C) Dysphagia
D) Frequent nosebleeds

A

(Feedback:
Cromolyn (Nasalcrom) inhibits the release of histamine and other chemicals. It is prescribed to treat allergic rhinitis. Beta-adrenergic agents lead to bronchodilation and stimulate beta-2 adrenergic receptors in the smooth muscle of the bronchi and bronchioles. It does not affect proton pump action or the sodium-potassium pump in the nasal cells.)

The nurse is caring for a patient who needs education on his medication therapy for allergic rhinitis. The patient is to take cromolyn (Nasalcrom) daily. In providing education for this patient, how should the nurse describe the action of the medication?

A) It inhibits the release of histamine and other chemicals.
B) It inhibits the action of proton pumps.
C) It inhibits the action of the sodium-potassium pump in the nasal epithelium.
D) It causes bronchodilation and relaxes smooth muscle in the bronchi.

D

(Feedback:
A cotton tampon may be used to try to stop the bleeding. The use of ice on the bridge of the nose has no scientific rationale for care. Laying the client down on the cot could block the client's airway. Hospital admission is necessary only if the bleeding becomes serious.)

The campus nurse at a university is assessing a 21-year-old student who presents with a severe nosebleed. The site of bleeding appears to be the anterior portion of the nasal septum. The nurse instructs the student to tilt her head forward and the nurse applies pressure to the nose, but the student's nose continues to bleed. Which intervention should the nurse next implement?

A) Apply ice to the bridge of her nose
B) Lay the patient down on a cot
C) Arrange for transfer to the local ED
D) Insert a tampon in the affected nare

A

(Feedback:
Clear fluid from either nostril suggests a fracture of the cribriform plate with leakage of cerebrospinal fluid. The symptoms are not indicative of an abrasion of the soft tissue or rupture of a sinus. Clear fluid leakage from the nose would not be indicative of a fracture of the nasal septum.)

The ED nurse is assessing a young gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from her nose. What should the ED nurse suspect?

A) Fracture of the cribriform plate
B) Rupture of an ethmoid sinus
C) Abrasion of the soft tissue
D) Fracture of the nasal septum

D

(Feedback:
Immediately after the fracture, the nurse applies ice and encourages the patient to keep the head elevated. The nurse instructs the patient to apply ice packs to the nose to decrease swelling. Dependent positioning would exacerbate bleeding and the nose is not irrigated. Occlusive dressings are not used.)

A 42-year-old patient is admitted to the ED after an assault. The patient received blunt trauma to the face and has a suspected nasal fracture. Which of the following interventions should the nurse perform?

A) Administer nasal spray and apply an occlusive dressing to the patient's face.
B) Position the patient's head in a dependent position.
C) Irrigate the patient's nose with warm tap water.
D) Apply ice and keep the patient's head elevated.

C

(Feedback:
Hereditary angioedema is an inherited condition that is characterized by episodes of life-threatening laryngeal edema. No information supports lost days of work or reduced cardiac function.)

The occupational health nurse is obtaining a patient history during a pre-employment physical. During the history, the patient states that he has hereditary angioedema. The nurse should identify what implication of this health condition?

A) It will result in increased loss of work days.
B) It may cause episodes of weakness due to reduced cardiac output.
C) It can cause life-threatening airway obstruction.
D) It is unlikely to interfere with the individual's health.

B

(Feedback:
Considering the known risk factors for cancer of the larynx, it is essential to assess the patient's history of alcohol intake. Infection is a risk in the postoperative period, but not an appropriate answer based on the patient's history. Depression and nonadherence are risks in the postoperative phase, but would not be critical short-term assessments.)

The nurse is conducting a presurgical interview for a patient with laryngeal cancer. The patient states that he drinks approximately six to eight shots of vodka per day. It is imperative that the nurse inform the surgical team so the patient can be assessed for what?

A) Increased risk for infection
B) Delirium tremens
C) Depression
D) Nonadherence to postoperative care

D

(Feedback:
The use of topical decongestants is controversial because of the potential for a rebound effect. The patient should hold his or her head back for maximal distribution of the spray. Only the patient should use the bottle.)

The nurse is explaining the safe and effective administration of nasal spray to a patient with seasonal allergies. What information is most important to include in this teaching?

A) Finish the bottle of nasal spray to clear the infection effectively.
B) Nasal spray can only be shared between immediate family members.
C) Nasal spray should be administered in a prone position.
D) Overuse of nasal spray may cause rebound congestion.

D

(Feedback:
The nurse informs the patient about the need to take the full course of any prescribed antibiotic. Antibiotics should be taken for the entire 10-day period to eliminate the microorganisms. A patient should never be instructed to keep leftover antibiotics for use at a later time. Even if the fever or other symptoms are gone, the medications should be continued. Antibiotics do not need to be disposed of in a biohazard receptacle, though they should be discarded appropriately.)

As a clinic nurse, you are caring for a patient who has been prescribed an antibiotic for tonsillitis and has been instructed to take the antibiotic for 10 days. When you do a follow-up call with this patient, you are informed that the patient is feeling better and is stopping the medication after taking it for 4 days. What information should you provide to this patient?

A) Keep the remaining tablets for an infection at a later time.
B) Discontinue the medications if the fever is gone.
C) Dispose of the remaining medication in a biohazard receptacle.
D) Finish all the antibiotics to eliminate the organism completely.

A

(Feedback:
Chronic pharyngitis is common in adults who live and work in dusty surroundings, use the voice to excess, suffer from chronic chough, and habitually use alcohol and tobacco. Caffeine and spicy foods have not been linked to chronic pharyngitis. GERD is not a noted risk factor.)

A nurse practitioner has provided care for three different patients with chronic pharyngitis over the past several months. Which patients are at greatest risk for developing chronic pharyngitis?

A) Patients who are habitual users of alcohol and tobacco
B) Patients who are habitual users of caffeine and other stimulants
C) Patients who eat a diet high in spicy foods
D) Patients who have gastrointestinal reflux disease (GERD)

B

(Feedback:
Hemorrhage is a potential complication of a tonsillectomy. Increased pulse, fever, and restlessness may indicate a postoperative hemorrhage. Difficulty ambulating and bradycardia are not common complications in a patient after a tonsillectomy. Infrequent swallowing does not indicate hemorrhage; frequent swallowing does.)

The perioperative nurse has admitted a patient who has just underwent a tonsillectomy. The nurse's postoperative assessment should prioritize which of the following potential complications of this surgery?

A) Difficulty ambulating
B) Hemorrhage
C) Infrequent swallowing
D) Bradycardia

C

(Feedback:
Obstructive sleep apnea occurs in men, especially those who are older and overweight. Symptoms include excessive daytime sleepiness, insomnia, and snoring. Daytime sleepiness and difficulty going to sleep at night are not indications of tonsillitis or adenoiditis. This patient's symptoms are not suggestive of laryngeal cancer.)

A 45-year-old obese man arrives in a clinic with complaints of daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem?

A) Adenoiditis
B) Chronic tonsillitis
C) Obstructive sleep apnea
D) Laryngeal cancer

C

(Feedback:
Discharge teaching for prevention of epistaxis should include the following: avoid forceful nose bleeding, straining, high altitudes, and nasal trauma (nose picking). Adequate humidification may prevent drying of the nasal passages. Keeping nasal passages clear and using a tissue when blowing the nose are not included in discharge teaching for the prevention of epistaxis. Decongestants are not indicated.)

The nurse is caring for a patient in the ED for epistaxis. What information should the nurse include in patient discharge teaching as a way to prevent epistaxis?

A) Keep nasal passages clear.
B) Use decongestants regularly.
C) Humidify the indoor environment.
D) Use a tissue when blowing the nose.

D

(Feedback:
A common postoperative complication from this type of surgery is difficulty in swallowing, which creates a potential for aspiration. Cardiovascular complications are less likely at this stage of recovery. The patient's body image should be assessed, but dysphagia has the potential to affect the patient's airway, and is a consequent priority.)

The nurse is caring for a patient who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment?

A) Assessment of body image
B) Assessment of jugular venous pressure
C) Assessment of carotid pulse
D) Assessment of swallowing ability

B

(Feedback:
Beconase should be avoided in patients with recurrent epistaxis, glaucoma, and cataracts. Sinustop Pro and Afrin are pseudoephedrine and do not have a side effect of epistaxis. Singulair is a bronchodilator and does not have epistaxis as a side effect.)

The nurse is performing the health interview of a patient with chronic rhinosinusitis who experiences frequent nose bleeds. The nurse asks the patient about her current medication regimen. Which medication would put the patient at a higher risk for recurrent epistaxis?

A) Afrin
B) Beconase
C) Sinustop Pro
D) Singulair

B, C, E

(Feedback:
The nurse also assesses the patient's general state of nutrition, including height and weight and body mass index, and reviews laboratory values that assist in determining the patient's nutritional status (albumin, protein, glucose, and electrolyte levels). The white blood cell count and the platelet count would not normally assist in determining the patient's nutritional status.)

The nurse is performing an assessment on a patient who has been diagnosed with cancer of the larynx. Part of the nurse's assessment addresses the patient's general state of nutrition. Which laboratory values would be assessed when determining the nutritional status of the patient? Select all that apply.

A) White blood cell count
B) Protein level
C) Albumin level
D) Platelet count
E) Glucose level

C

(Feedback:
Patient education is essential when assisting the patient in the use of all medications. To prevent possible drug interactions, the patient is cautioned to read drug labels before taking any OTC medications. Some Web sites are reliable and valid information sources, but this is not always the case. Patients do not necessarily need to limit themselves to one pharmacy, though checking for potential interactions is important. Not all OTC medications are safe additions to prescription medication regimens.)

The nurse is teaching a patient with allergic rhinitis about the safe and effective use of his medications. What would be the most essential information to give this patient about preventing possible drug interactions?

A) Prescription medications can be safely supplemented with OTC medications.
B) Use only one pharmacy so the pharmacist can check drug interactions.
C) Read drug labels carefully before taking OTC medications.
D) Consult the Internet before selecting an OTC medication.

B

(Feedback:
URIs, specifically chronic rhinosinusitis and recurrent acute rhinosinusitis, may be linked to primary or secondary immune deficiency or treatment with immunosuppressive therapy (i.e., for cancer or organ transplantation). Typical symptoms may be blunted or absent due to immunosuppression. No evidence indicates damage to the transplanted organ due to chronic rhinosinusitis. Immunosuppressive drugs do not cause organ rejection.)

The nurse is caring for a patient who has just been diagnosed with chronic rhinosinusitis. While being admitted to the clinic, the patient asks, "Will this chronic infection hurt my new kidney?" What should the nurse know about chronic rhinosinusitis in patients who have had a transplant?

A) The patient will have exaggerated symptoms of rhinosinusitis due to immunosuppression.
B) Taking immunosuppressive drugs can contribute to chronic rhinosinusitis.
C) Chronic rhinosinusitis can damage the transplanted organ.
D) Immunosuppressive drugs can cause organ rejection.

B

(Feedback:
A compressed nasal sponge may be used. Once the sponge becomes saturated with blood or is moistened with a small amount of saline, it will expand and produce tamponade to halt the bleeding. The packing may remain in place for 48 hours or up to 5 or 6 days if necessary to control bleeding. Antibiotics may be prescribed because of the risk of iatrogenic sinusitis and toxic shock syndrome.)

The nurse is caring for a patient with a severe nosebleed. The physician inserts a nasal sponge and tells the patient it may have to remain in place up to 6 days before it is removed. The nurse should identify that this patient is at increased risk for what?

A) Viral sinusitis
B) Toxic shock syndrome
C) Pharyngitis
D) Adenoiditis

C

(Feedback:
Nursing care for patients with viral pharyngitis focuses on symptomatic management. Antibiotics are not prescribed for viral etiologies. Surgery is not indicated in the treatment of viral pharyngitis. Chronic hoarseness is not a common sequela of viral pharyngitis, so teaching ways to prevent it would be of no use in this instance.)

A nursing student is discussing a patient with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for patients with viral pharyngitis?

A) Teaching focuses on safe and effective use of antibiotics.
B) The patient should be preliminarily screened for surgery.
C) Symptom management is the main focus of medical and nursing care.
D) The focus of care is resting the voice to prevent chronic hoarseness.

A

(Feedback:
Patient teaching is an important aspect of nursing care for the patient with acute rhinosinusitis. The nurse instructs the patient about symptoms of complications that require immediate follow-up. Referral to a physician is indicated if periorbital edema and severe pain on palpation occur. Clear drainage and blood-tinged mucus do not require follow-up if the patient has acute rhinosinusitis. A persistent headache does not necessarily warrant immediate follow-up.)

The nurse is providing patient teaching to a patient diagnosed with acute rhinosinusitis. For what possible complication should the nurse teach the patient to seek immediate follow-up?

A) Periorbital edema
B) Headache unrelieved by OTC medications
C) Clear drainage from nose
D) Blood-tinged mucus when blowing the nose

B

(Feedback:
Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. Antibiotic resistance is not relevant to viral illnesses and OTC medications do not have a "rebound" effect. Genetic factors do not exist.)

A patient states that her family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to what factor?

A) Cold viruses are increasingly resistant to common antibiotics.
B) The virus is shed for 2 days prior to the emergence of symptoms.
C) A genetic predisposition to viral rhinitis has recently been identified.
D) Overuse of OTC cold remedies creates a "rebound" susceptibility to future colds.

C

(Feedback:
Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. The benefits of this treatment depend on the degree of heat that is applied. The nurse teaches about these procedures and about the recommended temperature of the solution: high enough to be effective and as warm as the patient can tolerate, usually 105ºF to 110ºF (40.6ºC to 43.3ºC). Irrigating the throat may reduce spasm in the pharyngeal muscles and relieve soreness of the throat. You would not tell the parent teacher organization that there is no real treatment of pharyngitis.)

It is cold season and the school nurse been asked to provide an educational event for the parent teacher organization of the local elementary school. What should the nurse include in teaching about the treatment of pharyngitis?

A) Pharyngitis is more common in children whose immunizations are not up to date.
B) There are no effective, evidence-based treatments for pharyngitis.
C) Use of warm saline gargles or throat irrigations can relieve symptoms.
D) Heat may increase the spasms in pharyngeal muscles.

B

(Feedback:
The nurse explains how to apply direct pressure to the nose with the thumb and the index finger for 15 minutes in case of a recurrent nosebleed. If recurrent bleeding cannot be stopped, the patient is instructed to seek additional medical attention. ASA is not contraindicated in most cases and the patient should avoiding blowing the nose for an extended period of time, not just 45 minutes.)

The nurse is doing discharge teaching in the ED with a patient who had a nosebleed. What should the nurse include in the discharge teaching of this patient?

A) Avoid blowing the nose for the next 45 minutes.
B) In case of recurrence, apply direct pressure for 15 minutes.
C) Do not take aspirin for the next 2 weeks.
D) Seek immediate medical attention if the nosebleed recurs.

B

(Feedback:
Due to the risk for aspiration, the nurse keeps a suction setup available in the hospital and instructs the family to do so at home for use if needed. TPN is not indicated and small meals do not necessarily reduce the risk of aspiration. Physical therapists do not address swallowing ability.)

The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk?

A) Facilitate total parenteral nutrition (TPN).
B) Keep a complete suction setup at the bedside.
C) Feed the patient several small meals daily.
D) Refer the patient for occupational therapy.

A

(Feedback:
Patients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Thus, accurate assessment of patients with these tubes is critical. Use of a nasogastric tube is not associated with the development of the other listed pathologies.)

A patient has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to what complication?

A) Sinus infections
B) Esophageal strictures
C) Pharyngitis
D) Laryngitis

B

(Feedback:
Antimicrobial agents (antibiotics) should not be used because they do not affect the virus or reduce the incidence of bacterial complications. In addition, their inappropriate use has been implicated in development of organisms resistant to therapy. It would be inappropriate to tell the patient that the physician will not respond to her request.)

A mother calls the clinic asking for a prescription for Amoxicillin for her 2-year-old son who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother?

A) "I will relay your request promptly to the doctor, but I suspect that she won't get back to you if it's a cold."
B) "I'll certainly inform the doctor, but if it is a cold, antibiotics won't be used because they do not affect the virus."
C) "I'll phone in the prescription for you since it can be prescribed by the pharmacist."
D) "Amoxicillin is not likely the best antibiotic, but I'll call in the right prescription for you."

B

(Feedback:
The patient with a laryngectomy is a risk for airway occlusion and respiratory distress. As in all nursing situations, assessment of the airway is a priority over other potential complications and assessment parameters.)

The nurse is providing care for a patient who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize?

A) The patient's swallowing ability
B) The patient's airway patency
C) The patient's carotid pulses
D) Signs and symptoms of infection

C

(Feedback:
The nurse promptly notifies the surgeon of any active bleeding, which can occur at a variety of sites, including the surgical site, drains, and trachea. The drain should not be removed or connected to suction. Supine positioning would exacerbate the bleeding. Vitamin K would not be administered without an order.)

The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a patient who is postoperative day 1 following total laryngectomy. How should the nurse respond to this development?

A) Remove the patient's drain and apply pressure with a sterile gauze.
B) Assess the patient, reposition the patient supine, and apply wall suction to the drain.
C) Rapidly assess the patient and notify the surgeon about the patient's bleeding.
D) Administer a STAT dose of vitamin K to aid coagulation.

C

(Feedback:
Tracheoesophageal puncture is simple and has few complications. It is associated with high phonation success, good phonation quality, and steady long-term results. As a result, it is preferred over esophageal speech, and electric larynx or ASL.)

The nurse is creating a care plan for a patient who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. What form of alaryngeal communication will likely be chosen?

A) Esophageal speech
B) Electric larynx
C) Tracheoesophageal puncture
D) American sign language (ASL)

C

(Feedback:
A liquid or soft diet is provided during the acute stage of the disease, depending on the patient's appetite and the degree of discomfort that occurs with swallowing. The patient is encouraged to drink as much fluid as possible (at least 2 to 3 L/day). There is no need for increased potassium or protein intake.)

A patient is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the patient's nutrition during treatment?

A) A 1.5 L/day fluid restriction
B) A high-potassium, low-sodium diet
C) A liquid or soft diet
D) A high-protein diet

B

(Feedback:
The incidence of distant metastasis with squamous cell carcinoma of the head and neck (including larynx cancer) is relatively low. The patient's prognosis is determined by the oncologist, but the patient has asked a general question and it would be inappropriate to refuse a response. The nurse must not downplay the patient's concerns.)

A patient has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the patient asks, "Does this kind of cancer tend to spread to other parts of the body?" What is the nurse's best response?

A) "In many cases, this type of cancer spreads to other parts of the body."
B) "This cancer usually does not spread to distant sites in the body."
C) "You will have to speak to your oncologist about that."
D) "Squamous cell carcinoma is nothing to be concerned about, so try to focus on your health."

C

(Feedback:
Informational materials (written and audiovisual) about the surgery are given to the patient and family for review and reinforcement. The nurse never gives personal contact information to the patient. Nothing in the scenario indicates that a referral to a social worker or psychologist is necessary. False reassurance must always be avoided.)

The nurse is performing preoperative teaching with a patient who has cancer of the larynx. After completing patient teaching, what would be most important for the nurse to do?

A) Give the patient his or her cell phone number.
B) Refer the patient to a social worker or psychologist.
C) Provide the patient with audiovisual materials about the surgery.
D) Reassure the patient and family that everything will be alright.

D

(Feedback:
In patients receiving transesophageal puncture, a valve is placed in the tracheal stoma to divert air into the esophagus and out the mouth. Once the puncture is surgically created and has healed, a voice prosthesis (Blom-Singer®) is fitted over the puncture site. A nasogastric tube and belching are not required. An artificial pharynx is not used.)

A patient's total laryngectomy has created a need for alaryngeal speech which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the patient when teaching him about this process?

A) Training on how to perform controlled belching
B) Use of an electronically enhanced artificial pharynx
C) Insertion of a specialized nasogastric tube
D) Fitting for a voice prosthesis

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