ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 20 : Caring for Clients With Upper Respiratory Disorders Questions
Question 1 of 5
The nurse is providing discharge instructions to a client diagnosed with postoperative tonsillectomy and adenoidectomy. Which discharge instruction(s) would the nurse include? Select all that apply.
Correct Answer: B,C,D,E
Rationale: A client may be at risk for postoperative bleeding for several days following the surgical procedure as the scab may be removed from the surgical site early causing the bleeding. Clients should avoid carbonated beverages and citrus fluids or foods because these agents are caustic to the suture line. The client should gradually increase fluids from thin liquids to thick liquids then soft foods through the recovery process. Applying an ice collar and gargling with saline decreases swelling and aids in preventing infection. Pain medication would be appropriate throughout the day, not just at night.
Question 2 of 5
The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply.
Correct Answer: B,C,E,F
Rationale: The nurse would be calling to report signs of respiratory distress. This includes nasal flaring with abdominal retractions, stridor and an increased respiratory effort. Also arterial blood gases with an elevated $\mathrm{CO}_2$ and lower oxygen level indicates respiratory compromise. An increased respiratory rate occurs in respiratorycompromise. Administration of a corticosteroid decreases inflammation over a period of time.
Question 3 of 5
A client had a tracheostomy two hours ago. The nurse assesses the client and finds the client's breathing is shallow, with a respiratory rate of 30 . The nurse notes increased mucus production around the tracheostomy and on the dressing. What is the priority nursing concern(s)? Select all that apply.
Correct Answer: A,D
Rationale: The client with a new tracheostomy tube has increased secretions, which may become dried and occlude or plug the airway, requiring frequent suctioning. Impaired gas exchange and airway clearance are priority nursing concerns. Infection, knowledge deficit, and altered body image are concerns, but not priorities.
Question 4 of 5
The nurse is an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factor(s) would the nurse be sure to include in the workshop? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Carcinogens, such as tobacco, alcobol, and industrial pollutants, are associated with laryngeal cancer. The age of the client is also a factor, with a higher incidence among those 65 years of age or older. Region of country lived in is notassociated with laryngeal cancer as a specific risk factor.
Question 5 of 5
The nurse is providing tracheostomy care for a client. Place the following steps in the order the nurse should perform them.
Correct Answer: C,A,B,D,E,G,F
Rationale: The nurse should position client in a supine or low Fowler position. Using a clean glove, the nurse should remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle. The nurse should then open the tracheostomy kit without contaminating the contents. The nurse should don sterile gloves, keeping the dominant hand sterile. Next, the nurse should pour hydrogen peroxide and normalsaline into respective containers. The nurse should then unlock the inner cannula by turning it counterclockwise, afterward removing it and placing it in hydrogen peroxide. The nurse should clean the inside and outside of the cannula with pipe cleaners. Next, the nurse should rinse the cleaned cannula with normal saline. The nurse should then tap the cannula and wipe the excess solution with sterile gauze. Next, the nurse should replace the inner cannula and turn it clockwise within the outer cannula. The nurseshould then clean around the stoma with an applicator moistened with normal saline.Next, the nurse should place a sterile dressing around the tracheostomy tube andchange the tracheostomy ties by placing the new ones on first and removing the soiled ones last. Finally, the nurse should tie the new ends securely, but not tightly, at theside of the neck. The nurse should perform hand hygiene before, during, and after the procedure.