Introduction
When caring for a patient with a tracheostomy, the priority assessment is focused on airway and breathing. Therefore, the most critical examination for this patient would be c. respiratory rate and oxygen saturation. While other reviews such as electrolyte levels, daily weights, speech and swallowing, pain, and mobility may also be necessary, ensuring the patient’s airway and respiratory status is the primary concern.
Before performing tracheostomy cannula care for a patient with a tracheostomy tube after reconstructive surgery for invasive head and neck cancer, the nurse should assess the quality of breath sounds. Option b. quality of breath sounds is the most critical assessment in this scenario. Auscultating lung sounds helps determine the presence of secretions, which must be cleared to prevent aspiration before proceeding with tracheostomy cannula care. Assessing the patient’s level of consciousness, presence of the gag reflex, and tracheostomy cuff pressure are essential but not the immediate priority in this context.
NR 324 Week 2 Upper Respiratory System
When administering seasonal influenza vaccinations to long-term care facility residents, a contraindication to administering the vaccine would be a d—history of a severe allergic reaction. If a resident has a documented history of a severe allergic reaction to the vaccine, such as an anaphylactic reaction, it would be contraindicated to administer the vaccine. This is often related to a hypersensitivity to eggs since the vaccine is produced in eggs. Advanced age (a) and a history of respiratory illness (b), such as chronic obstructive pulmonary disease (COPD), are not contraindications for the influenza vaccination. When caring for a stable patient with a tracheostomy, the registered nurse (RN) can delegate the task of b—suctioning the patient’s oropharynx to unlicensed assistive personnel (UAP) who have been trained in the correct technique. Assessing the need for suctioning should be performed by an RN or licensed practical nurse. Evaluating the patient’s swallowing ability and maintaining appropriate cuff inflation pressure should also be done solely by the RN.
To determine if a patient’s upper respiratory infection (URI) has developed into acute sinusitis, the nurse should assess for d. maxillary pain or pressure. Maxillary pain or pressure is a clinical indicator specific to acute sinusitis. While coughing and fever are nonspecific clinical indicators of a URI, they do not definitively indicate acute sinusitis. Additionally, a history of a dust allergy that may affect the upper respiratory tract can support a diagnosis of sinusitis, but it is not specific to sinusitis alone. When reviewing a patient’s health history with laryngeal cancer, the nurse would expect to find d—chronic use of alcohol and tobacco products. Tobacco use is the leading cause of head and neck cancers, including laryngeal cancer, accounting for 85% of cases. Excessive alcohol consumption is another significant risk factor. Other risk factors for laryngeal cancer include exposure to the sun, asbestos, industrial carcinogens, marijuana use, radiation therapy to the head and neck, and poor oral hygiene.
NR 324 Week 2 Upper Respiratory System
For a patient admitted for joint replacement surgery with a permanent tracheostomy, the nurse can delegate the task of d. providing oral care with a toothbrush and tonsil suction tube to unlicensed assistive personnel (UAP). UAP can safely perform oral care for a stable patient with a tracheostomy. However, tasks such as suctioning the tracheostomy (a), checking the stoma site for skin breakdown (b), and completing tracheostomy care using sterile technique (c) should be performed by a registered nurse, as they require specialized skills and assessments.
The nurse determines that medication teaching for using budesonide intranasal spray for seasonal allergic rhinitis is successful if the patient makes the statement: d. “I will use the medication every day of the season whether I have symptoms or not.” Budesonide should be used regularly, starting two weeks before the pollen season begins and continuing throughout the season, even if the patient is not experiencing symptoms. This helps to reduce inflammation and manage symptoms effectively. The medication does not provide immediate relief within minutes (b), does not impact liver function (a), and does not significantly increase the risk of serious infections (c).
NR 324 Week 2 Upper Respiratory System
When caring for a patient who is 3 hours postoperative laryngectomy, the nurse’s highest priority assessment is b—airway patency. Airway patency is always the highest priority, especially in patients with surgery involving the upper respiratory system. Ensuring the patient’s airway remains clear and unobstructed is crucial for breathing and oxygenation. While patient comfort (a), incisional drainage (c), and vital signs (d) are critical assessments, they follow the priority of maintaining airway patency.
The priority action by the nurse when a patient’s tracheostomy tube is expelled by coughing 30 minutes after insertion in the post-anesthesia recovery unit is b. to maintain the airway with a sterile hemostat. A sterile hemostat is necessary to keep the airway open until a clean tracheostomy tube can be reinserted into the tracheal opening. This ensures that the patient’s breathing is not compromised. If the patient is in respiratory distress, temporary ventilation using an Ambu bag and mask (c) may be required. Suctioning the tracheostomy opening (a) can be performed after the airway is secured, and inserting the tracheostomy tube obturator into the stoma (d) is inappropriate.
