Nokea
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
- A. Incrusted mucous membranes
- B. Hardened secretions
- C. Erosion of the trachea
- D. Noisy breathing
Correct Answer: D
Rationale: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following atracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.
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The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?
- A. A ventilator
- B. A face mask
- C. A rigid shell
- D. A nasal cannula
Correct Answer: B
Rationale: A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device.
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.
- A. A decreased respiratory rate
- B. Arterial blood gases reporting a $\mathrm{PaCO}_2$ of 48 and a $\mathrm{PaO}_2$ of 84
- C. Nasal flaring with abdominal retractions
- D. Administration of a corticosteroid inhaler for quick relief
- E. Lung sounds of wheezing
- F. Increased respiratory effort
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.
The nurse is caring for a client who is status post nasal polypectomy. What would the nurse instruct this client to report?
- A. Excessive swallowing
- B. Nasal stuffiness
- C. Diarrhea
- D. Coughing
Correct Answer: A
Rationale: The nurse inspects the nasal packing and dressings frequently for bleeding and asks the client to report excessive swallowing, which can indicate bleeding. Nasal stuffiness and diarrhea do not indicate postoperative bleeding. Coughing can loosen or expel scabs on the surgical wounds.
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?
- A. Epistaxis, twice last week
- B. Aphonia following a football game
- C. Hoarseness for 2 weeks
- D. Laryngitis following a cold
Correct Answer: C
Rationale: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity.
The nurse is caring for a client with an upper respiratory disorder. The client states they have a hacky, nonproductive cough, which wakens them during the night. Which over-the-counter medication would the nurse suggest to diminish the cough during the night?
- A. Diphenhydramine
- B. Dextromethorphan
- C. Pseudoephedrine
- D. Fluticasone
Correct Answer: B
Rationale: Dextromethorphan acts on the central nervous system to raise the cough threshold and dampen the cough reflex. Diphenhydramine is an antihistamine that relieves symptoms associated with allergies. Pseudoephedrine relieves nasalcongestion associated with sinusitis, colds, and allergies. Fluticasone reduces tissue edema.