Exam 26: Upper Respiratory Problems

Which action should the nurse take first when a patient develops epistaxis?

The nurse is caring for a hospitalized older patient who has nasal packing in place after a nosebleed. Which assessment finding will require the most immediate action by the nurse?

After a laryngectomy,a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?

The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider?

The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care?

Which nursing action could the registered nurse (RN)working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN)caring for a patient with a permanent tracheostomy?

The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems? (Put a comma and a space between each answer choice [A,B,C,D].)

A patient arrives in the ear,nose,and throat clinic complaining of a piece of tissue being "stuck up my nose" and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first?

When assessing a patient with a sore throat,the nurse notes anterior cervical lymph node swelling,a temperature of 101.6° F (38.7° C),and yellow patches on the tonsils. Which action will the nurse anticipate taking?

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would determine if the cuff has been properly inflated?

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse,"Will I be able to talk normally after surgery?" What is the most accurate response by the nurse?

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask?

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse indicates that this identified problem is resolving?

The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session ?

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist?

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination ?

The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions,what action should the nurse take?

The nurse discusses management of upper respiratory infections (URIs)with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed?

Which patient in the ear,nose,and throat (ENT)clinic should the nurse assess first?

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action?