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The nurse is mentoring a new graduate nurse and the two are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. Which complication(s) would the nurse identify for the new nurse? Select all that apply.
- A. Absence of secretions
- B. Aspiration
- C. Infection
- D. Injury to the laryngeal nerve
- E. Penetration of the anterior tracheal wall
Correct Answer: B,C,D
Rationale: The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall.
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The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently?
- A. Airway patency
- B. Level of consciousness
- C. Psychological status
- D. Pain level
Correct Answer: A
Rationale: The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation. The priorities are always airway, breathing, and then circulation.
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.
- A. Alcohol
- B. Age
- C. Tobacco
- D. Industrial pollutants
- E. Region of country lived in
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.
The nurse is caring for a client who is post-sinus surgery. When assessing the client, the nurse asks how many the nurse is holding up. Why does the nurse assess postoperative visual acuity?
- A. To assess possible hemorrhage
- B. To assess damage to the optic nerve
- C. To assess postoperative infection
- D. To assess impaired drainage
Correct Answer: B
Rationale: A client who has undergone a sinus surgery faces a serious risk of damage to the optic nerve. Therefore, the nurse assesses postoperative visual acuity by asking the client to identify the number of fingers displayed. To assess possible hemorrhage, the nurse observes the client for repeated swallowing. The nurse assesses for pain over the involved sinuses and not a postoperative infection or an impaired drainage.
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 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.