Chapter 29

Upper Respiratory Problems

Answer Keys for Questions

• Rationales for Bridge to NCLEX Examination Questions

1. Correct answer: c

Rationale: The nurse should teach the patient about home care before discharge: to avoid

vigorous nose blowing, strenuous activity, lifting, and straining for 4 to 6 weeks; to sneeze with

the mouth open; and to avoid the use of aspirin-containing products. You would not teach the

patient to insert more packing into a nose with packing already in-situ.

2. Correct answer: d

Rationale: An important intervention involves identifying and avoiding triggers of allergic

reactions. The nurse should have the patient keep a diary of times when the allergic reaction

occurs and of the activities that precipitate the reaction.

3. Correct answers: a, c, d, e

Rationale: The goals of nursing management are infection control, symptom relief, and

prevention of secondary complications. Antibiotics are not prescribed until the cause is known.

Unnecessary antibiotic use leads to the development of antibiotic-resistant organisms. A

thorough history and a throat culture help identify the cause. Encourage the patient with

pharyngitis to increase fluid intake. Cool, bland liquids and gelatin do not irritate the pharynx;

citrus juices are often irritating.

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4. Correct Answer: b

Rationale: The child has pain with symptoms typical of strept throat. Relieving the patient’s

pain and fever using acetaminophen is a priority. Morphine IV is not recommended, nor is

providing IV fluid as there is nothing to indicate a hydration issue. Documentation is important,

but is not the most important, as the patient’s sore throat and fever take priority.

5. Correct answer: a

Rationale: The ability to swallow secretions without aspiration has traditionally been evaluated

with the use of blue dye; however, this method is no longer recommended. Instead, clinical

assessment by a speech therapist, video-fluoroscopy, or fiberoptic endoscopic evaluations of

swallow are recommended. Patients should begin swallowing with thickened liquids, not plain

water. Ability to swallow should be assessed with the cuff deflated, because cuff inflation may

interfere with swallowing ability.

6. Correct answer: d

Rationale: A patient with a tracheostomy is at risk for hypoxemia during and after suctioning.

Pre-oxygenate patients with 100% FIO2 prior to suctioning. Monitor the patient’s O2 status

before, during, and after suctioning. Routine instillation of normal saline via ET tube or

tracheostomy is no longer recommended.

7. Correct answers: a, b, d, e

Rationale: Tobacco use causes 85% of head and neck cancers. Excess alcohol consumption and

sun exposure are other risk factors. Head and neck cancers in those younger than 50 years of age

have been associated with human papillomavirus (HPV) infection.

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7. Correct answer: b, e

Rationale: Secretions are initially blood-tinged and then decrease in amount and become less

bloody over time. Placing the patient in semi-Fowler’s position will facilitate drainage. Normal

saline through the tracheostomy tube is not recommended to help with removal of thickened

secretions because it causes hypoxia and may contribute to the development of

ventilatorassociated pneumonia (VAP). There is no sign that the patient has respiratory distress,

so use of the bag-valve-mask is not appropriate.

8. Correct answers: b, c, d

Rationale: Although regular exercise is important, shoulder and arm exercises are

contraindicated. The nurse would teach the patient not to swim, as water entering the laryngeal

stoma would risk choking and aspiration. All the other activities identified (including cleaning

around the stoma daily with a damp, moist washcloth, providing pictures and “hands-on” time to

practice for tracheostomy care, and encouraging the patient to join a support group with other

laryngectomees) are appropriate.

• Answer Guidelines for Case Study in the text.

1. Recognize: What assessment information suggests M.R. was at risk for laryngeal cancer?

Cancer of the larynx is strongly associated with prolonged use of tobacco and alcohol, which are

both risk factors for M.R. Hypertension is also correlated with increased risk of cancer.

2. Recognize: What factors may affect wound healing after surgery?

M.R.’s history of smoking, alcohol intake, and type 2 diabetes may affect wound healing after

surgery. If M.R.’s weight loss is enough to cause a nutritional deficiency, this could affect

wound healing.

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3. Prioritize: What are your priority teaching strategies for M.R. before his total laryngectomy?

Preoperative teaching for M.R. should include information about the surgery and the expected

changes in speech resulting from laryngectomy. Show a communication method that can be

used temporarily or permanently after surgery. Explain that after surgery he will be placed in an

upright position with a tube in his throat that he will breathe through. Describe the presence of

tubes and drains for wound management and gastrointestinal suctioning. Explain that after the

breathing tube is removed, there will be a stoma (or opening) for a permanent airway. Explain to

M.R. how he will eat after surgery. Tell him that enteral feeding will be used preoperatively to

help improve his nutritional status and will continue postoperatively until he completes any

planned radiation therapy or is able to swallow. General preoperative teaching should include

deep breathing, coughing, and pain management.

4. Act: How would you explain the gastrostomy tube to M.R.?

Explain to M.R. that a gastrostomy tube (also known as a G-tube) is a tube that is placed into the

stomach. It will be inserted by the surgeon, under local anesthesia, with medication being given

for discomfort. Given that it will not be possible to eat and drink through the mouth in the

immediate postoperative period, this tube delivers nutrition directly into the stomach.

5. Analzye: What information would you want to know from the ICU nurse who has just

transported M.R. to the clinical unit?

Successful patient handover and exchange of pertinent information is essential for safe patient

care. Upon transfer from the ICU, the clinical nurse may want to know:

• Central nervous system: What is M.R.’s level of consciousness? How much has he needed for

pain? When was his last does of analgesic and/or sedative?

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• Cardiovascular: What is his temperature? What are his vital signs (heart rate and rhythm,

respiratory rate and rhythm, BP, SpO2?) Have you had any problems with heart rate,

respiratory rate, and/or BP?

• Integument: What does the dressing look like on his neck? Is it dry and intact? Have you had

to change the dressing? Are there any surgical drains? If so, what type and how many? How

much have they each drained in the past 24 hours?

• Respiratory: What did you hear when you auscultated his chest? How long has the been in

place? How much O2 is he currently receiving?

• Gastrointestinal: Has he been fed yet? If so, how have you been feeding him? At what rate?

Any untoward complications since his feeding was started?

• Genitourinary: Does he have a urinary catheter or is he voiding independently? What does his

urine look like? How much urine has he produced in the past 24 hours?

• Fluid balance: Does he have a positive or negative fluid balance?

• Lab values: Is M.R.’s hemoglobin stable? Are all electrolyte levels within normal values? How

has M.R.’s blood glucose values been?

• Psychosocial: What has M.R.’s mood been like? Has M.R. had any visitors since his

surgery?

6. Prioritize: Based on the assessment data presented, what are your priority clinical problems?

Impaired respiratory function, impaired communication, pain, nutritional compromised, risk for

aspiration, impaired tissue integrity, difficulty coping, altered blood pressure

7. Act: How could you best meet M.R.’s communication needs during the first few

postoperative days?

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Alphabet boards, writing materials, pictorial guides, or hand gestures are useful methods for

communicating. Integrating technology into patient care enhances the patient’s ability to

communicate basic needs postoperatively. Using tablet computers and smartphones for texting

and digital voice are options.

8. Act: Four hours after transfer to the clinical unit, M.R. is tearful and is staring at the wall.

What should you do?

Discuss with M.R. that many of the physical changes are reversible as the edema subsides and

the tracheostomy tube is removed. Encourage verbalization of feelings and expression of

emotions. Convey acceptance to help the patient regain an acceptable self-concept.

8. Safety: What teaching is required to help him assume self-care after his surgery? What

precautions should he take because of his stoma?

Self-care requires that the patient learn to care for the laryngectomy stoma and, if needed, give

tube feedings. Stoma care involves cleansing the skin around the stoma, removing and cleaning

both the inner cannula and the entire laryngectomy tube if it is in place, and suctioning the

laryngectomy tube when needed. Teach M.R. to use a bedside humidifier to keep secretions

liquefied.

Precautions that the patient should take with the stoma include covering the stoma before

shaving to avoid inhalation of foreign materials, using loose clothing (shirt) to shield the stoma,

and using a plastic collar to prevent water from entering the stoma while showering. Because the

stoma is a direct route to the lungs, swimming is contraindicated. The patient should be taught to

compensate for the loss of smell by installing a smoke alarm.

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