quiz 17 nursing
What are the primary responsibilities for maintaining tracheostomy tube care? (SATA 4/6)
Maintain patient airway Keep inner cannula clean Prevent impairment of surrounding tissue Provide patient with means of communication
What is the best nursing intervention that should be included when taking care of a client with a tracheostomy tube? How will you communicate with the client?
-Provide client with materials for non verbal communication if necessary Ex: pen & paper -Use questions that can be answered by simple yes or no or by nodding head or hand signals
When suctioning client, it should be no greater than?
10 seconds
Nurse is preparing to suction a client with a tracheostomy tube. Which nursing action is appropriate & safe for this procedure? (SATA 4/5) (steps to suction client)
Assess lungs Saline lavage prior to suctioning to loosen secretions Hyperoxygenate patient prior to suctioning Use sterile gloved hand to suction Suction no greater than 10 seconds
What is the appropriate nursing action for a client with a 2-day old tracheostomy? How often would you clean the tube?
Clean trach tube at least once per shift
What kind of clothing can you encourage patient to wear when on oxygen therapy?
Cotton clothing
The nurse prepares to measure the client's oxygen saturation & notes edema of the client's hands & thickened toenails. Where can pulse ox be applied to measure oxygen saturation?
Earlobe
Provider is discharging client with prescription for home oxygen therapy. The nurse should reinforce which of the following instructions for the client & his family? (SATA 3/5)
Educate on O2 hazards & safety measures How to use at home equipment Fill humidifier bottle with distilled water only Deep breathing & coughing exercises
A client following a post op tracheostomy has copious & tenacious secretions. What can you provide to thin the client's secretions?
Humidified oxygen
What should be done prior to suctioning patient? What will be given to patient?
Hyperoxygenate to prevent hypoxia
What will be your nursing intervention that will help prevent hypoxia during suctioning prior trach care?
Hyperoxygenate with ventilator or ambu-bag
Nurse is caring for a patient that has pneumonia & has an oxygen saturation of 85%. Which of following actions should nurse take first?
Increase oxygen flow, Reposition patient to Semi-Fowlers or raise head of bed
The client requires suctioning for pulmonary secretions. What is the appropriate nursing diagnosis for this client?
Ineffective airway clearance
Nurse is taking care of a client that is immobile. What is the priority action for nurse to contribute to client's plan of care?
Monitor patient's respiratory status & airway, Reposition every 2 hours to promote maximum ventilation & lung expansion
What is the proper care of the suction catheter after each use?
Must be discarded properly after each use
A newly licensed nurse is suctioning a patient. What action should make charge nurse intervene?
Newly licensed nurse lubricates suction catheter with oil based jelly instead of water based
Client has difficulty breathing & is laying down in bed & is already receiving oxygen via nasal canula. Which of the following nursing interventions is priority?
Reposition client to Fowler's position
Nurse is planning a cost-effective intervention for a new client with a tracheostomy & decreased mobility. What would be the best simple & cost-effective intervention for reducing risk of pulmonary complication?
Reposition patient every 2 hours
When opening the suction catheter, the nurse should leave it in the wrapper & attach it to the suction machine. What is the purpose of attaching to suction machine?
To maintain sterility
What is the early stage of hypoxia?
elevated BP
When doing trach care for a client, which part of the trach tube will be removed for cleaning?
Inner cannula
When performing tracheostomy care to a client, what should be your action when changing or securing the neck ties?
Secure new trach ties before removing old ones
What cleaning solution is appropriate to use when cleansing the inner canula of a tracheostomy tube?
50% hydrogen peroxide, 50% saline
A client who has pneumonia when nurse is collecting data & should identify adverse effects of oxygen therapy. What is an indication of an adverse effect of oxygen therapy?
Cracks in oral mucous membranes
Nurse is preparing to change the neck ties on a tracheostomy tube. In order to perform a safe procedure, what should the nurse plan to do?
Have 2nd health care member assist to stabilize trach
Which part of the trach should the secretions be removed from?
Inner cannula
What kind of concentration can nasal canula can provide?
Low concentration of oxygen as needed 1-6 L/min = 24% - 44% O2
Nurse is assisting care with a client who is 2-days post op following creation of a tracheostomy. Which of the following actions should the nurse plan to take?
Provide humidified air to prevent drying of pulmonary secretions
What are you trying to remove when suctioning a patient?
Pulmonary secretions
Nurse must be vigilant for signs of hypoxia in an older patient who has dementia & risk for decreased oxygenation because chronic respiratory disease & immobility. What is the late sign of hypoxia?
Respirations are slow & shallow
Client has respiratory insufficiency. What is an early sign of inadequate oxygenation?
Restlessness
Nurse is assessing a client with acute respiratory infection who is at risk for hypoxemia. What are the early indications that should alert the nurse that the client is developing hypoxia? (SATA 3/5)
Restlessness Tachypnea Confusion Hypertension
What is the recommended position when suctioning an alert & conscious patient?
Semi-Fowler's
What is the recommended position when suctioning an unconscious patient?
Side-lying
When assessing a patient with a tracheostomy, what are you observing during assessment of the stoma?
Signs of bleeding, purulent drainage, edema, or respiratory obstruction
