Week 10- Oxygenation and Critical Thinking

A child with cystic fibrosis is preparing for discharge, which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse's teaching? A. "I must flush the tube with water after feedings and clamp the tube." B. "I must check placement three times." C. "I will report to the doctor any signs of indigestion." D. "If my child is unable to swallow, I will discontinue the feeding and call the clinic."

A. "I must flush the tube with water after feedings and clamp the tube." Rationale: The client's family member should be taught to flush the tube after each feeding and clamp the tube. The placement should be checked before feedings, and indigestion can occur with the PEG tube, just as it can occur with any client, so answers B and C are incorrect. Medications can be ordered for indigestion, but it is not a reason for alarm. A percutaneous endoscopy gastrostomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing; therefore, answer D is incorrect.

The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside? A. A tracheotomy set B. A padded tongue blade C. An endotracheal tube D. An airway

A. A tracheotomy set Rationale: The client who has recently had a thyroidectomy is at risk for tracheal edema. A padded tongue blade is used for seizures and not for the client with tracheal edema, so answer B is incorrect. If the client experiences tracheal edema, the endotracheal tube or airway will not correct the problem, so answers C and D are incorrect.

The nurse is changing the ties of the client with a tracheotomy. The safest method of changing the tracheotomy ties is to: A. Apply the new tie before removing the old one. B. Have a helper present. C. Hold the tracheotomy with the nondominant hand while removing the old tie. D. Ask the doctor to suture the tracheostomy in place.

A. Apply the new tie before removing the old one. Rationale: The best method and safest way to change the ties of a tracheotomy is to apply the new ones before removing the old ones. B is incorrect because having a helper is good, but the helper might not prevent the client from coughing out the tracheotomy. Answer C is not the best way to prevent the client from coughing out the tracheotomy. D is incorrect because asking the doctor to suture the tracheotomy in place is not appropriate.

The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance? a. Suctioning respiratory secretions several times every hour b. Administering humidified oxygen through a tracheostomy collar c. Instilling normal saline into the tracheostomy to thin secretions before suctioning d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions

B. Administering humidified oxygen through a tracheostomy collar Rationale: Humidification of air will help keep the mucous membranes moist and will make secretions easier to expel. Suctioning should be done only as needed; too frequent suctioning can damage the mucosal lining, resulting in thicker secretions. Normal saline should never be instilled into a tracheostomy because this could lead to infection. The purpose of the tracheostomy cuff is to keep secretions from entering the lungs; the nurse should not deflate the tracheostomy cuff unless instructed to do so by the physician.

The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client's most appropriate priority nursing diagnosis? A. Alteration in cerebral tissue perfusion B. Fluid volume deficit C. Ineffective airway clearance D. Alteration in sensory perception

B. Fluid volume deficit Rationale: What causes BP to bottom out and pulse to go super high? Bleeding out. The vital signs indicate hypovolemic shock. They do not indicate cerebral tissue perfusion, airway clearance, or sensory perception alterations, so answers A, C, and D are incorrect. Go through you ABCs-- Airway and Breathing appear to be OK because respirations are normal. Circulation is impaired.

A patient has been brought into the recovery room after undergoing abdominal surgery. Several minutes after arrival, the nurse notes that the patients hands and feet are cool, his capillary refill is 6 seconds, and he has a dropping blood pressure. Which response from the nurse is most appropriate? A. Apply direct pressure to the abdomen B. Increase parenteral fluid as prescribed C. Lower the patients head and raise the feet D. Start a second IV in the antecubital fossa

B. Increase parenteral fluid as prescribed The recovery room is a crucial time for the nurse to assess the patients physiological status after he is recovering from surgery and coming out of anesthesia. The patient is at greater risk of blood loss from surgery; the nurse must be alert to signs or symptoms of this complication, including decreased perfusion and skin changes, and act quickly to prevent life-threatening consequences.

A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education? A) "I'll make sure that I rest between activities so I don't get so short of breath." B) "I'll rest for 30 minutes before I eat my meal." C) "If I have trouble breathing at night, I'll use two to three pillows to prop up." D) "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

D) "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

A patient with heart disease has developed pulmonary edema and is having difficulties breathing. The nurse notes that the patient is breathing at a rate of 28/min and has an oxygen saturation of 90% on room air. Which best describes the first response of the nurse? A. Administer pain medication to slow the patients breathing B. Prepare the patient for a thoracentesis C. Gather supplies to assist with intubation D. Administer oxygen through a face mask to correct saturation levels

D. Administer oxygen through a face mask to correct saturation levels Rationale: Pulmonary edema develops as increased congestion in the pulmonary system, making breathing difficult for the affected patient. In this situation, the patient is symptomatic and is struggling with decreased oxygen levels, which can lead to hypoxia. The first action of the nurse is to administer oxygen to correct oxygen saturation levels.

A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in four months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority? A. Impaired parenting related to activity intolerance B. Hypothermia r/t decreased metabolic rate C. Disturbed thought processes r/t interstitial edema D. Decreased cardiac output r/t bradycardia

D. Decreased cardiac output r/t bradycardia Rationale: The decrease in pulse can affect the cardiac output and lead to shock, which would take precedence over the other choices; therefore, answers A, B, and C are incorrect. Follow your ABCs-- bradycardia falls under C

A nurse is caring for a patient with a tracheostomy. The nurse notes that the patient has gurgling sounds coming from the trach site, he is breathing rapidly, and he is trying to cough. Which action should the nurse perform next? A. Replace the trach tubing with an ambu-bag and provide two measured breaths B. Assess the patients lung sounds C. Check capillary refill in the fingertips D. Suction the opening and the trach tubing

D. Suction the opening and the trach tubing Rationale: When a patient with a trach needs suctioning, the nurse may be able to hear or see secretions around the opening to the site. The patient may become restless and may breathe more rapidly or try to cough. Trach suctioning is a common event that is usually required on a regular basis for a patient with a tracheostomy.