What should the nurse including discharge teaching for the patient with a total laryngectomy?

Following a laryngectomy a patient coughs violently during suctioning and dislodges the
tracheostomy tube. Which action should the nurse take first?
a. Cover stoma with sterile gauze and ventilate through stoma.
b. Attempt to reinsert the tracheostomy tube with the obturator in place.
c. Assess the patient's oxygen saturation and notify the health care provider.
d. Ventilate the patient with a manual bag and face mask until the health care provider arrives.

ANS: B
The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway.
Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this
situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate
action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate
for a patient with a total laryngectomy because there is a complete separation between the upper airway
and the trachea.

The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical
neck dissection and notes the following problems. In which order should the nurse address the problems?
(Put a comma and a space between each answer choice [A, B, C, D].)
a. The patient is in a side-lying position with the head of the bed flat.
b. The patient is coughing blood-tinged secretions from the tracheostomy.
c. The nasogastric (NG) tube is disconnected from suction and clamped off.
d. The wound drain in the neck incision contains 200 mL of bloody drainage

ANS:
A, B, D, C
The patient should first be placed in a semi-Fowler's position to maintain the airway and reduce incisional
swelling. The blood-tinged secretions may obstruct the airway, so suctioning is the next appropriate action.
Then the wound drain should be drained because the 200 mL of drainage will decrease the amount of
suction in the wound drain and could lead to incisional swelling and poor healing. Finally, the NG tube should
be reconnected to suction to prevent gastric dilation, nausea, and vomiting

The nurse completes discharge instructions for a patient with a total laryngectomy. Which
statement by the patient indicates that additional instruction is needed?
a. "I must keep the stoma covered with an occlusive dressing at all times."
b. "I can participate in most of my prior fitness activities except swimming."
c. "I should wear a Medic-Alert bracelet that identifies me as a neck breather."
d. "I need to be sure that I have smoke and carbon monoxide detectors installed.

ANS: A
The stoma may be covered with clothing or a loose dressing,
but this is not essential. An occlusive dressing will completely
block the patient's airway. The other patient comments are all
accurate and indicate that the teaching has been effective

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube.
Which action by the nurse would best determine if the cuff has been properly inflated?
a. Use a manometer to ensure cuff pressure is at an appropriate level.
b. Check the amount of cuff pressure ordered by the health care provider.
c. Suction the patient first with a fenestrated inner cannula to clear secretions.
d. Insert the decannulation plug before the nonfenestrated inner cannula is removed.

ANS: A
Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will
avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy
tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patient's
airway is occluded. A health care provider's order is not required to determine safe cuff pressure. A
nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from
the suction catheter passing through the fenestrated openings

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection.
During the first 24 hours after surgery what is the priority nursing action?
a. Monitor for bleeding.
b. Maintain adequate IV fluid intake.
c. Suction tracheostomy every eight hours.
d. Keep the patient in semi-Fowler's position.

ANS: D
The most important goals after a laryngectomy and radical neck dissection are to maintain the airway and
ensure adequate oxygenation. Keeping the patient in a semi-Fowler's position will decrease edema and limit
tension on the suture lines to help ensure an open airway. Maintenance of IV fluids and monitoring for
bleeding are important, but maintaining an open airway is the priority. Tracheostomy care and suctioning
should be provided as needed. During the immediate postoperative period, the patient with a laryngectomy
requires frequent suctioning of the tracheostomy tube

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient
complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is most
important for the nurse to ask?
a. "How much alcohol do you drink in an average week?"
b. "Do you have a family history of head or neck cancer?"
c. "Have you had frequent streptococcal throat infections?"
d. "Do you use antihistamines for upper airway congestion?"

ANS: A
Prolonged alcohol use and smoking are associated with the development of laryngeal cancer,
which the patient's symptoms and history suggest. Family history is not a risk factor for head or
neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic
rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat
infections also may cause these clinical manifestations, but patients with this type of infection
will also have pain and a fever

A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If
the patient is unsuccessful in coughing up secretions, what action should the nurse take?
a. Encourage increased incentive spirometer use.
b. Encourage the patient to increase oral fluid intake.
c. Put on sterile gloves and use a sterile catheter to suction.
d. Preoxygenate the patient for 3 minutes before suctioning

ANS: C
This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile
catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not
necessary. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can
mobilize secretions. However, the patient with a tracheostomy may not be able to use an
incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize
secretions in a timely manner

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able
to talk normally after surgery?" What is the best response by the nurse?
a. "You will breathe through a permanent opening in your neck, but you will not be able to communicate orally."
b. "You won't be able to talk right after surgery, but you will be able to speak again after the tracheostomy tube is removed."
c. "You won't be able to speak as you used to, but there are artificial voice devices that will give you the ability to speak
normally."
d. "You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice
restoration."

ANS: D
Voice rehabilitation is planned after a total laryngectomy, and a variety of assistive devices are
available to restore communication. Although the ability to communicate orally is changed, it
would not be appropriate to tell a patient that this ability would be lost. Artificial voice devices
do not permit normal-sounding speech. In a total laryngectomy, the vocal cords are removed,
so normal speech is impossible.

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of
personal care. Which information obtained by the nurse is the best indicator that this identified problem is
resolving?
a. The patient lets the spouse provide tracheostomy care.
b. The patient allows the nurse to suction the tracheostomy.
c. The patient asks how to clean the tracheostomy stoma and tube.
d. The patient uses a communication board to request "No Visitors."

ANS: C
Independently caring for the laryngectomy tube indicates that the patient
has regained control of personal care and hopelessness is at least partially
resolved. Letting the nurse and spouse provide care and requesting no
visitors may indicate that the patient is still experiencing hopelessness

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which
action should the nurse include in the plan of care in collaboration with the speech therapist?
a. Leave the tracheostomy inner cannula inserted at all times.
b. Place the decannulation cap in the tube before cuff deflation.
c. Assess the ability to swallow before using the fenestrated tube.
d. Inflate the tracheostomy cuff during use of the fenestrated tube.

ANS: C
Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration
should be assessed before changing to a fenestrated tracheostomy tube. The decannulation
cap is never inserted before cuff deflation because to do so would obstruct the patient's
airway. The cuff is deflated and the inner cannula removed to allow air to flow across the
patient's vocal cords when using a fenestrated tube

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an
experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent
tracheostomy?
a. Assess the patient's risk for aspiration.
b. Suction the tracheostomy when needed.
c. Teach the patient about self-care of the tracheostomy.
d. Determine the need for replacement of the tracheostomy tube.

ANS: B
Suctioning of a stable patient can be delegated to
LPNs/LVNs. Patient assessment and patient
teaching should be done by the RN

Which statement by the patient indicates that the teaching has been effective for a patient
scheduled for radiation therapy of the larynx?
a. "I will need to buy a water bottle to carry with me."
b. "I should not use any lotions on my neck and throat."
c. "Until the radiation is complete, I may have diarrhea."
d. "Alcohol-based mouthwashes will help clean oral ulcers

ANS: A
Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will
damage tissues at the site being radiated but should not affect the abdominal organs, so loose
stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing
with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used
on radiated skin, although they should not be used just before the radiation therapy