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Nursing Management:
102 Chapter 27 Nursing Management: Upper Respiratory Problems
8. What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction?
a. A tracheostomy is safer to perform in an emergency.
b. An ET tube has a higher risk of tracheal pressure necrosis.
c. A tracheostomy tube allows for more comfort and mobility.
d. An ET tube is more likely to lead to lower respiratory tract infection.
9. What are the characteristics of a fenestrated tracheostomy tube (select all that apply)?
a. The cuff passively fills with air.
b. Cuff pressure monitoring is not required.
c. It has two tubings with one opening just above the cuff.
d. Patient can speak with an attached air source with the cuff inflated.
e. Airway obstruction is likely if the exact steps are not followed to produce speech.
f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted.
10. During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula.
To care for the tracheostomy appropriately, what should the nurse do?
a. Deflate the cuff, then remove and suction the inner cannula.
b. Remove the inner cannula and replace it per institutional guidelines.
c. Remove the inner cannula if the patient shows signs of airway obstruction.
d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube.
11. Which actions prevent the dislodgement of a tracheostomy tube in the first 3 days after its placement (select all that apply)?
a. Provide tracheostomy care every 24 hours.
b. Keep the patient in the semi-Fowler position at all times.
c. Keep a same size or larger replacement tube at the bedside.
d. Tracheostomy ties are not changed for 24 hours after tracheostomy procedure.
e. Suction the tracheostomy tube when there is a moist cough or a decreased SpO2.
f. A physician performs the first tube change, no sooner than 7 days after the tracheostomy.
12. Delegation Decision: In planning the care for a patient with a tracheostomy who has been stable and is to be discharged later in the day, the RN may delegate which interventions to the licensed practical nurse (LPN) (select all that apply)?
a. Suction the tracheostomy.
b. Provide tracheostomy care.
c. Determine the need for suctioning.
d. Assess the patient’s swallowing ability.
e. Teach the patient about home tracheostomy care.
13. What is included in the nursing care of the patient with a cuffed tracheostomy tube?
a. Change the tube every 3 days.
b. Monitor cuff pressure every 8 hours.
c. Perform mouth care every 12 hours.
d. Assess arterial blood gases every 8 hours.
14. Priority Decision: A patient’s tracheostomy tube becomes dislodged with vigorous coughing. What should be the nurse’s first action?
a. Attempt to replace the tube.
b. Notify the health care provider.
c. Place the patient in high Fowler position.
d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives.
Chapter 27 Nursing Management: Upper Respiratory Problems 103 15. When obtaining a health history from a patient with possible cancer of the mouth, what would the nurse expect the
patient to report?
a. Long-term denture use
b. Heavy tobacco and/or alcohol use c. Persistent swelling of the neck and face
d. Chronic herpes simplex infections of the mouth and lips
16. The patient has been diagnosed with an early vocal cord malignancy. The nurse explains that usual treatment includes
a. radiation therapy that preserves the quality of the voice.
b. a hemilaryngectomy that prevents the need for a tracheostomy.
c. a radical neck dissection that removes possible sites of metastasis.
d. a total laryngectomy to prevent development of second primary cancers.
17. During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include?
a. The postoperative use of nonverbal communication techniques
b. Techniques that will be used to alleviate a dry mouth and prevent stomatitis c. The need for frequent, vigorous coughing in the first 24 hours postoperatively d. Self-help groups and community resources for patients with cancer of the larynx
18. When assessing the patient on return to the surgical unit following a total laryngectomy and radical neck dissection, what would the nurse expect to find?
a. A closed-wound drainage system b. A nasal endotracheal tube in place
c. A nasogastric tube with orders for tube feedings d. A tracheostomy tube and mechanical ventilation
19. Following a supraglottic laryngectomy, the patient is taught how to use the supraglottic swallow to minimize the risk of aspiration. In teaching the patient about this technique, what should the nurse instruct the patient to do?
a. Perform Valsalva maneuver immediately after swallowing.
b. Breathe between each Valsalva maneuver and cough sequence.
c. Cough after swallowing to remove food from the top of the vocal cords.
d. Practice swallowing thin, watery fluids before attempting to swallow solid foods.
20. What should the nurse include in discharge teaching for the patient with a total laryngectomy?
a. How to use esophageal speech to communicate b. How to use a mirror to suction the tracheostomy c. The necessity of never covering the laryngectomy stoma d. The need to use baths instead of showers for personal hygiene
21. What is the most normal functioning method of speech restoration in the patient with a total laryngectomy?
a. Esophageal speech b. A transesophageal puncture c. An electrolarynx held to the neck d. An electrolarynx placed in the mouth
104 Chapter 27 Nursing Management: Upper Respiratory Problems
CASE STUDY Rhinoplasty Patient Profile
F.N. is a 28-year-old male patient who sustained bilateral fractures of the nose, three rib fractures, and a comminuted fracture of the tibia in an automobile crash 5 days ago. An open reduction and internal fixation of the tibia were per- formed the day of the trauma. F.N. is now scheduled for a rhinoplasty to reestablish an adequate airway and improve cosmetic appearance.
Subjective Data
• Reports facial pain at a level of 6 on a 10-point scale
• Expresses concern about his facial appearance
• Complains of dry mouth Objective Data
• RR 24
• HR 68 bpm
• Bilateral ecchymosis of eyes (raccoon eyes)
• Periorbital edema and edema of face reduced by about half since second hospital day
• Has been NPO since midnight in preparation for surgery
Discussion Questions
Using a separate sheet of paper, answer the following questions:
1. When F.N. was admitted, examination of his nose revealed clear drainage. What is the significance of the drainage?
What testing is indicated?
2. What is the reason for delaying repair of F.N.’s nose for several days after the trauma?
3. What measures should be taken to maintain F.N.’s airway before and after surgery?
4. Priority Decision: When F.N. arrives in the postanesthesia care unit (PACU) following surgery, what priority assessments should the nurse make in the immediate postoperative period?
5. Priority Decision: F.N.’s nasal packing is removed in 24 hours and he is to be discharged. What priority predischarge teaching should the nurse provide?
6. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?
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1. How do microorganisms reach the lungs and cause pneumonia (select all that apply)?
a. Aspiration b. Lymphatic spread
c. Inhalation of microbes in the air
d. Touch contact with the infectious microbes
e. Hematogenous spread from infections elsewhere in the body
2. Why is the classification of pneumonia as community-acquired pneumonia (CAP) or medical care-associated pneumonia (MCAP) clinically useful?
a. Atypical pneumonia syndrome is more likely to occur in MCAP.
b. Diagnostic testing does not have to be used to identify causative agents.
c. Causative agents can be predicted and empiric treatment is often effective.
d. IV antibiotic therapy is necessary for MCAP but oral therapy is adequate for CAP.
3. The microorganisms Pneumocystis jiroveci (PCP) and cytomegalovirus (CMV) are associated with which type of pneumonia?
a. Bronchial pneumonia c. Hospital-associated pneumonia
b. Opportunistic pneumonia d. Community-acquired pneumonia
4. Which of the following microorganisms are associated with both CAP and MCAP (select all that apply)?
a. Klebsiella d. Mycoplasma pneumonia
b. Staphylococcus aureus e. Pseudomonas aeruginosa
c. Haemophilus influenzae f. Streptococcus pneumonia
5. Place the most common pathophysiologic stages of pneumonia in order. Number the first stage with 1 and the last stage with 4.
a. Macrophages lyse the debris and normal lung tissue and function is restored.
b. Mucus production increases and can obstruct airflow and further decrease gas exchange.
c. Inflammatory response in the lungs with neutrophils is activated to engulf and kill the offending organism.
d. Increased capillary permeability contributes to alveolar filling with organisms and neutrophils interrupt normal oxygen transportation.
6. When obtaining a health history from a 76-year-old patient with suspected CAP, what does the nurse expect the patient or caregiver to report?
a. Confusion c. An abrupt onset of fever and chills
b. A recent loss of consciousness d. A gradual onset of headache and sore throat 7. What is the initial antibiotic treatment for pneumonia based on?
a. The severity of symptoms
b. The presence of characteristic leukocytes c. Gram stains and cultures of sputum specimens
d. History and physical examination and characteristic chest x-ray findings
8. Priority Decision: After the health care provider sees a patient hospitalized with a stroke who developed a fever and adventitious lung sounds, the following orders are written. Which order should the nurse implement first?
a. Anterior/posterior and lateral chest x-rays
b. Start IV levofloxacin (Levaquin) 500 mg every 24 hr c. Sputum specimen for Gram stain and culture and sensitivity
d. Complete blood count (CBC) with white blood cell (WBC) count and differential