Chapter 28- Trach and O2
A client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care? A. "I can only take baths, but no showers." B. "I can put normal saline in my tracheostomy to keep the secretions from getting thick." C. "I should put cotton or foam over the tracheostomy hole." D. "I will have to learn to suction myself." E. "I will be unable to wear a necklace."
A, B, C, E
A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device will the nurse select? A. face tent B. Venturi mask C. nasal cannula D. non-rebreather mask
A.
A client who has a "do not resuscitate" (DNR) prescription has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first? A. Ensure that the tubing is patent and that oxygen flow is high B. Notify the chaplain and the family member of record C. Call the Rapid Response Team (RRT) and prepare to intubate D. Comfort the client.
A.
A client with chronic obstructive pulmonary disease (COPD) has a prescription to adjust oxygen to maintain SpO2 between 90% and 92%. Which action can be delegated to an unlicensed assistive personnel (UAP) under the supervision of an RN? A. Adjust the position of the oxygen tubing B. Assess for signs and symptoms of hypoventilation. C. Change the O2 flow rate to keep SpO2 as prescribed D. Select the O2 delivery device used for the client
A.
A client with respiratory failure has been intubated and placed on a ventilator with 100% oxygen delivery to maintain adequate saturation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds. The most recent arterial blood gases (ABGs) show a PaO2 level of 95 mm Hg. What action will the nurse take next? A. Collaborate with the provider to lower the FiO2 level B. Discuss the need for extubation due to the need for 100% oxygen C. Suggest noninvasive positive airway pressure techniques with oxygen D. Prepare to suction the client
A.
A registered nurse (RN) from the orthopedic unit has been assigned to the medical unit for the day. Which client assignment for the reassigned RN is the best? A. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula B. The client with chronic lung disease who is being evaluated for possible home oxygen use C. The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar D. The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask
A.
The nurse is caring for a group of clients on a medical surgical unit. Which client will the nurse assess first? A. A client admitted 2 hours ago who has a 90 pack-year smoking history and is receiving 50% oxygen by Venturi mask B. A client who has had a tracheostomy for 1 week, who has SpO2 of 95%-97% and foul-smelling drainage on the tracheostomy ties C. A client who is being discharged with a new prescription for home oxygen therapy by nasal cannula D. A client who is being discharged with a new prescription for home oxygen therapy by nasal cannula
A.
The nurse on a pulmonary unit is caring for a client who has had a tracheostomy placed earlier today. Which of these techniques representing best practice will use the nurse use when suctioning the client's tracheostomy tube? A. Hyperoxygenate before and after suctioning B. Repeat suctioning until the tube is clear C. Apply suction during insertion of the tube. D. Suction through the tracheostomy tube for 30 seconds
A.
The nurse is planning to provide tracheostomy care for a client with a soiled tracheostomy dressing. Which of these actions would be included in the plan of care? A. cut a sterile 4 × 4 gauze to fit around the tracheostomy tube B. Suction the client if needed. C. Cleanse the inner cannula with a mixture of peroxide and saline. D. Replace the dressing with a sterile, folded 4 × 4 gauze. E. Provide clean tracheostomy ties that fit snugly against the neck.
B,C,D
A client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response? A. "But you know you need this to breathe, right?" B. "Do you have a light scarf that you could place over it?" C. "Your family and friends probably won't even care." D. "It won't take you long to learn to manage."
B.
A client with pneumonia is receiving 100% oxygen via a non-rebreather mask. Which of these situations requires immediate intervention by the nurse? A. The client's skin has pink color B. The oxygen reservoir deflates during inspiration C. The client has crackles at the lung bases D. The client is expectorating rust colored sputum
B.
A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the inner cannula and the tracheostomy tube. Which action should the nurse take first? A. Auscultate the client's breath sounds while applying a nasal cannula. B. Direct someone to call the Rapid Response Team (RRT) while using a resuscitation bag and facemask C. Apply a 100% non-rebreather mask while administering high-flow oxygen. D. Replace the obturator while reinserting the tracheostomy tube.
B.
An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? A. Complete the referral form for a home health agency B. Suction the tracheostomy using sterile technique C. Teach the client and spouse about tracheostomy care D. Consult with the health care provider (HCP) about using a fenestrated tube
B.
A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first? A. Suction as needed B. Clean the tracheostomy inner cannula and stoma C. Auscultate lung sounds D. Change the tracheostomy dressing as needed.
C.
The adult client with degenerative arthritis is admitted for surgery to create a tracheostomy. What is the best communication method for this client during the postoperative period? A. Computer keyboard B. Magic Slate C. Picture board D. Pen and paper
C.
The interprofessional team is collaborating about using noninvasive positive-pressure ventilation (NPPV) for a confused client with pneumonia. What information is essential for the nurse to share with the team while making this decision? A. The client requires frequent respiratory assessment B. NPPV uses positive pressure to keep the alveoli open C. The client is unable to cough and protect the airway D. A full face mask may not fit this client's small face well.
C.
The nurse is developing the plan of care to reduce risk for aspiration for a client with a tracheostomy. Which nursing interventions would be included in the plan of care? A. Encourage frequent sipping from a cup. B. Encourage water with meals. C. Inflate the tracheostomy cuff during meals. D. Maintain the client upright for 30 minutes after eating. E. Provide small, frequent meals. F. Teach the client to "tuck" the chin down in the forward position to swallow
D, E, F
A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response? A. "You can quit when you are ready." B. "It's never too late to quit." C. "For safety, turn off your oxygen when you smoke." D. "Let's discuss why smoking around oxygen is dangerous."
D.
The nurse is caring for a client who has had a tracheostomy placed yesterday. Which of these assessments is essential for the nurse to make? A.Measure the cuff pressure. B. Assess the color and consistency of secretions. C. Ensure a second tracheostomy tube is available. D. Assess for tachypnea.
D.
The nurse is caring for a client with COPD who has a prescription for supplemental oxygen. Which situation will cause the nurse to further assess the need to increase the fraction of inspired oxygen (FiO2)? A. Client's last ECG showed atrial fibrillation at a rate of 82 B. Client's blood pressure is 106/80 C. Client has been cooperative with all treatments D. Client has developed restlessness over the last hour
D.
The respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tubing is clear. What is the best immediate action by the nurse? A. Humidify the oxygen source B. Increase provided oxygenation C. Remove the inner cannula of the tracheostomy D. Suction the tracheostomy tube
D.