Chapter 26: Concepts Of Care For Patients With Noninfectious Upper Respiratory Problems Flashcards
When answering the call light for a client on bedrest, the nurse finds the client’s visitor unconscious on the floor with no discernable pulse and not breathing. The nurse estimates that at least 2 minutes have passed since the client’s light first came on. What is the nurse’s priority action?
A. Initiate CPR with chest compressions.
B. Perform an abdominal thrust maneuver.
C. Assess the visitor for the presence of a head injury.
D. Ask the client what event lead up to the visitor’s fall.
Answer: A
Rationale:
Abdominal thrust maneuver is performed on an unconscious patient instead of chest compressions only when a known obstruction is present. If no obstruction has been observed in an unconscious person, chest compressions are started instead of abdominal thrusts because more unconscious adults have cardiac problems rather than airway obstruction. The fact that the visitor has no discernable pulse is an indication of a cardiac dysrhythmia causing the problem. Time is critical to a successful resuscitation outcome. Assessing for a head injury and ask the client to relate events would delay the intervention.
Which information is most relevant for the nurse to teach a client about CPAP therapy for OSA? Select all that apply.
A. Avoid alcoholic beverages or drugs that make you sleepy within 3 hours of bed time.
B. Clean the mask device daily.
C. Ensure your mask device fits tightly enough to prevent airleaks.
D. Keep open flames such as candles out of the room when CPAP is in use.
E. Seal the mask edges to your face with petroleum jelly.
F. Use only sterile water in the humidifier tank.
G. Use the CPAP during all sleep periods, especially in bed.
H. Do not share your mask or tubing system with others.
Answers: B, C, G, H
Rationale:
CPAP is effective only when the mask device can provide positive pressure to the upper airways, which requires a mask that fits tightly enough to prevent airleaks. However, sealing the mask with any type of gel or cream is not recommended. Such products can damage the mask and the skin (when pressure is present). The respiratory tract is moist and harbors many microorganisms. The moisture can promote growth of such organisms. The mask should be cleaned daily according to manufacturer’s directions. Clean the tubing system as often as the manufacturer recommends. The mask and tubing system should not be shared with anyone else to prevent acquiring an infection. Most humidification tanks are to be filled with distilled water but the water does not need to be sterile. Open flames are not restricted because CPAP uses only room air and does not involve increased oxygen levels. CPAP should be used whenever the client sleeps in a prone position. Some respiratory health care providers also recommend its use even when the client naps in a chair.
Which nursing action has the highest priority when caring for a client with any type of facial or laryngeal trauma?
A. Managing pain.
B. Providing nutrition.
C. Assessing self-image.
D. Maintaining a patent airway.
Answer: D
Rationale:
Facial and laryngeal trauma have the potential to interfere with breathing by occluding the upper airways. This can occur from swelling, tissue displacement, bleeding, emesis, or as a response to therapy. Maintaining a patent airway remains a nursing priority until the trauma has healed.
A client who is 5 days post-operative from radical neck surgery for head and neck cancer tells the nurse that he is worried because his right shoulder is lower than the left and does not go back into place when he tries to raise it. What is the nurse’s best response?
A. “I will notify the surgeon right away because some left over tumor must be pressing on the nerve.”
B. “The nerve to the shoulder was removed during surgery. Physical therapy will help you to use other muscles to regain some motion.”
C. “This problem is not related to your surgery. If it persists after you go home you will need to see your primary health care provider about it.”
D. “Your time under anesthesia was long and you are not yet fully recovered. It is likely you will regain full motion in that shoulder by the end of the week.”
Answer: B
Rationale:
Radical neck dissection for head and neck cancer includes the removal of lymph nodes, the sternocleidomastoid muscle, the jugular vein, the 11th cranial nerve, and surrounding soft tissue. Shoulder drop is expected after extensive surgery. Although physical therapy can help ease the shoulder drop by using other muscle groups. However, full shoulder motion does not return. The problem is not related to pressure on the nerve or the length of anesthesia.
When making rounds, the nurse observe that a cognitively impaired client has a partial airway obstruction from inspissation. What is the nurse’s priority action?
A. Place the bed in reverse Trendelenburg position apply humidified oxygen by nasal cannula.
B. Check the flow sheet to assess for trends in the client’s oxygen saturation patterns.
C. Determine which nursing assistant provided this client’s morning care today.
D. Immediately provide complete oral care to this client.
Answer: D
Rationale:
Thickly crusted oral and nasopharyngeal secretions, a condition formally called inspissated secretions or mucoid impaction. It is most often caused by poor oral hygiene with thickened and hardened oral secretions that can completely block the airway and lead to death. A partial obstruction can quickly lead to a complete obstruction and asphyxiation. The priority action is to clear the obstruction. In this case proper nursing care with complete oral hygiene done immediately can eliminate prevent this partial obstruction from becoming a complete obstruction. Inspissation occurs over time and this client’s oral hygiene has been neglected, requiring that the nurse address this issue with all care personnel to ensure it does not happen again. However, the first priority is removing the obstruction. Applying oxygen by any route does not resolve the issue nor dose placing the client in reverse Trendelenburg position. Checking trends in oxygen saturation patterns does not help the immediate problem and only delays critical action.
A client with severe angioedema and tongue swelling from a drug allergy, has stridor and an oxygen saturation of 60%. For which type of respiratory support does the nurse prepare?
A. Nasal CPAP
B. Tracheotomy
C. Cricothyroidotomy
D. Endotracheal intubation
Answer: C
Rationale:
Stridor is a sound made from a laryngeal obstruction, not just an oral obstruction. The fact that her oxygen saturation is so low indicates this is a critical emergence and that her airway is going to become completely obstructed very soon. Nasal biPAP is not at all helpful here and it is unlikely that endotracheal intubation would be successful with this much edema. A tracheotomy would work but takes more time. Also, because this is a temporary condition that should respond well to drug therapy, the cricothyroidotomy is the best choice and this is what the nurse should have prepared for the Rapid Response Team.
A client has just come to the floor after an inner maxillary fixation for a mandibular fracture with wiring of the jaws. As the nurse raises the head of the bed, the client starts to vomit a large amount of liquid vomitus. What is the nurse’s priority action?
A. Administer the prescribed anti-emetic by the intravenous or rectal route.
B. Immediately notify the surgeon, the anesthesiologist, or the rapid response team.
C. Cut the wires holding his jaws together, and carefully remove them from the mouth.
D. Reposition the client to the side and suction the mouth mouth with a large-bore catheter.
Answer: D
Rationale:
The client is in danger of aspirating the vomitus. Repositioning to side-lying and suctioning the vomitus are the most important first actions for preventing this potentially life-threatening complication. The risk for aspiration is immediate and the anti-emetic will not stop the current episode of vomiting. If repositioning and suctioning are not effective, cutting the wires would be appropriate second action. Notifying other health care professionals is not correct because aspiration could occur before any of them get to the bedside. Positioning and suctioning are nursing actions that are likely to prevent the immediate complication.
In preparing a client with head and neck cancer (pharyngeal) for radiation therapy, which side effects does the nurse teach the client to expect? Select all that apply.
A. Scalp and eyebrow alopecia
B. Taste sensation loss or changes
C. Bloody and purulent sinus drainage
D. Increased risk for skin breakdown
E. Moderate weight gain
F. Increased risk for cavities
G. Gastroesophageal reflux
H. A persistent blue-tinge color to the skin and mucous membranes around the mouth
Answers: D, B, F
Rationale:
Radiation therapy is local and side effects appear in the tissues and organs that are in the radiation path. The tongue and teeth will receive some radiation, as will the salivary glands, causing some degree of dry mouth. The tooth irradiation and the dry mouth increase the risk for dental cavities. The tongue irradiation leads to taste loss or change. The skin in the radiation field or path is damaged and remains at high risk for skin breakdown for the time of radiation therapy and for months after this therapy is complete. Although the skin and mucous membranes in the radiation field are irritated, they do not become cyanotic. The eyebrows, scalp, and sinuses are not in the path and will not be affected. Weight is more often lost rather than gained because of taste changes and general soreness of the area. The treatment does not result in changes in the lower esophagus and does not increase the risk for gastroesophageal reflux.
Which client will the nurse consider to be at greatest risk for an airway obstruction?
A. A 25 year old with a sinus infection
B. A 65 year old who has chronic mouth dryness and many dental caries
C. A 35 year old with a traumatic brain injury
D. A 55 year old who wears upper and lower dentures
CORRECT: C
A 35 year old with a traumatic brain injury
What is the nurse’s best response to a client with obstructive sleep apnea (OSA) who asks, “Why does it feel like I wake up every 5 minutes?”
A. “Carbon dioxide builds up while you are not breathing, which stimulates your body to wake up and breathe.”
B. “Excessive sleeping during the day interferes with deeper sleep at night.”
C. “Your tongue may be blocking your throat, and you wake up because you are choking.”
D. “You really aren’t waking up that often. It just feels that way.”
CORRECT: A
“Carbon dioxide builds up while you are not breathing, which stimulates your body to wake up and breathe.”
Which associated health problems will the nurse expect a client with long-term obstructive sleep apnea (OSA) to have?
A. Hypertension and weight gain
B. Cancer and autoimmune disorders
C. Hypotension and chronic hypoglycemia
D. Asthma and chronic obstructive pulmonary disease
CORRECT: A
Hypertension and weight gain
Which client will the nurse consider to be a poor candidate for continuous positive airway pressure (CPAP) management for obstructive sleep apnea?
A. A 65 year old with chronic confusion
B. A 45 year old with septal deviation who is a mouth-breather
C. A 75 year old who lives alone
D. A 55 year old with an unusually large uvula
CORRECT: A
A 65 year old with chronic confusion
Which action will the nurse take first when a client with obstructive sleep apnea (OSA) who has been using continuous positive airway pressure (CPAP) with a facemask, returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness?
A. Reminding the client that sleep is important and to go ahead and take daytime naps
B. Asking the client whether the mask fits tightly over the mouth and nose
C. Encouraging the client to consider using over-the-counter sleep aids for deeper sleeping at night
D. Suggesting that a nasal mask be used instead of a nose and mouth facemask
CORRECT: B
Asking the client whether the mask fits tightly over the mouth and nose
Which oral hygiene measures will the nurse teach a client to use during the first week after having modified uvulopalatopharyngoplasty (modUPPP) surgery?
A. Rinsing with mouthwash and gently wiping oral structures with oral sponges
B. Only flossing and forgoing toothbrushing
C. Avoiding all oral hygiene practices except saline rinses
D. Swishing and swallowing an oral antibiotic solution
CORRECT: A
Rinsing with mouthwash and gently wiping oral structures with oral sponges
What is the priority assessment the will make for a client with a posterior nosebleed who has posterior packing and is receiving oxygen therapy, antibiotics, and opioid analgesics. What is the priority assessment?
A. Determining the degree of mouth dryness
B. Examining the skin around the nares for breakdown
C. Checking gag and cough reflexes
D. Asking about pain relief
CORRECT: C
Checking gag and cough reflexes
