Ignat Ch 28: Care of Patients Requiring Oxygen Therapy or Tracheostomy Flashcards
A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?
a. 14%
b. 21%
c. 28%
d. 31%
ANS: B
Room air is 21% oxygen.
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
a. Administer prescribed anxiolytic medication.
b. Ensure informed consent is on the chart.
c. Reinforce any teaching done previously.
d. Start the preoperative antibiotic infusion.
ANS: B
Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority?
a. Assess the clients oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest.
ANS: A
This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?
a. Elevate the head of the clients bed.
b. Measure and compare cuff pressures.
c. Place the client on NPO status.
d. Request that the client have a swallow study.
ANS: B
Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not correct this situation.
An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?
a. Assess the clients lung sounds.
b. Assign a different UAP to the client.
c. Report the UAP to the manager.
d. Request thicker liquids for meals.
ANS: A
The priority is to check the clients oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP should have reported the incident immediately, but addressing that issue is not the immediate priority.
A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor?
a. Holding the device securely when changing ties
b. Suctioning the client first if secretions are present
c. Tying a square knot at the back of the neck
d. Using half-strength peroxide for cleansing
ANS: C
To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot should be placed at the side of the clients neck, not in back. The other actions are appropriate.
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
a. Applying suction while inserting the catheter
b. Preoxygenating the client prior to suctioning
c. Suctioning for a total of three times if needed
d. Suctioning for only 10 to 15 seconds each time
ANS: A
Suction should only be applied while withdrawing the catheter. The other actions are appropriate.
A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met?
a. 100% of meals being eaten by the client
b. Intact skin behind the ears
c. The client understanding the need for oxygen
d. Unchanged weight for the past 3 days
ANS: B
Oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosis of Risk for Impaired Skin Integrity. Intact skin behind the ears indicates that goals for this diagnosis are being met. Nutrition and weight are not related to using oxygen. Understanding the need for oxygen is important but would not take priority over a physical problem.
A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate?
a. Call the operating room to inform them of a pending emergency case.
b. No action is needed at this time; this is a normal finding in some clients.
c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
d. Stay with the client and have someone else call the provider immediately.
ANS: D
This client may have a tracheainnominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery.
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
a. The client demonstrates good understanding of stoma care.
b. The client has joined a book club that meets at the library.
c. Family members take turns assisting with stoma care.
d. Skin around the stoma is intact without signs of infection.
ANS: B
The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for Impaired Self-Esteem are being met. The other findings are all positive signs but do not relate to this nursing diagnosis.
A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?
a. Apply water-soluble ointment to nares and lips.
b. Periodically turn the oxygen down or off.
c. Remove the tubing from the clients nose.
d. Turn the client every 2 hours or as needed.
ANS: A
Oxygen can be drying, so the UAP can apply water-soluble lubricant to the clients lips and nares. The UAP should not adjust the oxygen flow rate or remove the tubing. Turning the client is not related to comfort measures for oxygen.
A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best?
a. Assess the clients oxygen saturation and, if normal, turn off the oxygen.
b. Determine if the client can switch to a nasal cannula during the meal.
c. Have the client lift the mask off the face when taking bites of food.
d. Turn the oxygen off while the client eats the meal and then restart it.
ANS: B
Oxygen is a drug that needs to be delivered constantly. The nurse should determine if the provider has approved switching to a nasal cannula during meals. If not, the nurse should consult with the provider about this issue. The oxygen should not be turned off. Lifting the mask to eat will alter the FiO2 delivered.
The nurse assesses the client using the device pictured below to deliver 50% O2: The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best?
a. Assess the clients oxygen saturation.
b. Document these findings in the chart.
c. Immediately increase the flow rate.
d. Turn the flow rate down to 2 L/min.
ANS: C
For the Venturi mask to deliver high flow of oxygen, the flow rate must be set correctly, usually between 4 and 10 L/min. The clients flow rate is too low and the nurse should increase it. After increasing the flow rate, the nurse assesses the oxygen saturation and documents the findings.
A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.)
a. The client does not allow smoking in the house.
b. Electrical cords are in good working order.
c. Flammable liquids are stored in the garage.
d. Household light bulbs are the fluorescent type.
e. The client does not have pets inside the home.
ANS: A, B, C
Oxygen is an accelerant, which means it enhances combustion, so precautions are needed whenever using it. The nurse should assess if the client allows smoking near the oxygen, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety.
A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Applying water-soluble lip balm to the clients lips
b. Ensuring the humidification provided is adequate
c. Performing oral care with alcohol-based mouthwash
d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy
ANS: A, D
The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring the humidity is adequate and suctioning through the tracheostomy are nursing functions.
