TERM 4 Ch 28 Care of Patients Requiring Oxygen Therapy or Tracheostomy

A client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care? 1 "I can only take baths, but no showers." 2 "I can put normal saline in my tracheostomy to keep the secretions from getting thick." 3 "I should put cotton or foam over the tracheostomy hole." 4 "I will have to learn to suction myself."

"I can only take baths, but no showers." The client does not understand that he or she can shower with the use of a shower shield over the tracheostomy tube to prevent water from entering the airway. Additional teaching is necessary. Normal saline should be instilled into the artificial airway 10-15 times a day, as prescribed. The stoma should be covered with cotton or foam to protect it during the day; this filters the air entering the stoma, keeps humidity in the airway, and enhances appearance. Clients with tracheostomies should be taught clean suction technique.

A client being discharged home after being diagnosed with chronic obstructive respiratory syndrome (COPD) will require home oxygen therapy. Which statement by the client's spouse indicates that further teaching is required? 1 "We will not allow smoking at our home." 2 "We have several fire extinguishers, and we know how to use them." 3 "Our grandson will blow out the birthday candles for her at the party." 4 "We will return to the hospital if she seems to be having trouble breathing."

"Our grandson will blow out the birthday candles for her at the party." Oxygen is combustible and open flames like matches and candles should not be used in the immediate vicinity. Smoking should not be allowed in the same room when oxygen is in use. Knowing how to use a fire extinguisher correctly is important. The client should return to the hospital for further evaluation if respiratory distress develops.

A client requiring prolonged mechanical ventilation after laryngeal trauma is scheduled for tracheostomy surgery. What does the nurse include when teaching this client about the reason for this surgery? 1 "The tracheostomy will help the trauma site to heal faster." 2 "The tracheostomy will help prevent respiratory infection." 3 "This may make it possible to stop using the ventilator." 4 "You will be able to talk and eat once you have a tracheostomy."

"This may make it possible to stop using the ventilator." A tracheostomy placed for clients with laryngeal trauma will essentially bypass the damaged airway and improve the client's ability to breathe without mechanical ventilation. It does not help the trauma site to heal faster or prevent respiratory infection. Clients with a tracheostomy will eventually be able to eat and speak, but not immediately.

A prescription for oxygen therapy for a client who has been on a Venturi mask indicates a need for 80% Fio2. What do the options to fulfill this order include? Select all that apply. 1 T-piece adapter 2 Tracheostomy collar 3 Increased flow rate 4 Aerosol mask 5 Face tent

-Aerosol mask -Face tent A Venturi mask can deliver 34% to 50% Fio2 with flow rates of 4-10 L/min. An aerosol mask or face tent could deliver the ordered 80% Fio2 with a flow rate of at least 10 L/min. If the client had a tracheostomy, he or she could use a tracheostomy collar, or could use a T-piece with an endotracheal tube, but would not have had a Venturi mask.

and facilitate suctioning? Select all that apply. 1 Attach a warming device to the humidification water source. 2 Ensure intake of fluids is adequate. 3 Periodically instill 10 mL of sterile water into the tracheostomy. 4 Increase the flow rate of the air flow meter. 5 Drain condensation in the tubing back toward the tracheostomy

-Ensure intake of fluids is adequate. -Periodically instill 10 mL of sterile water into the tracheostomy. -Drain condensation in the tubing back toward the tracheostomy A warming device enhances humidification. When a client is adequately hydrated, tracheal secretions are thinner. Increasing the flow rate increases the passage of air through the humidifier and enhances humidification. It is not within the nurse's scope of practice to instill water into the tracheostomy. Condensation should be drained away from the airway to protect from aspiration and infection.

Which principles are important for the nurse to remember about oxygen administration? Select all that apply. 1 Oxygen is harmless; it is part of what we breathe normally and toxicity is unlikely. 2 High levels of oxygen dilute the nitrogen in the lungs leading to alveolar collapse. 3 When a client experiences air hunger, increase the Paco2 to improve the balance. 4 It is important to keep the client's Pao2 at greater than 90 mm Hg for optimal outcomes. 5 Nitrogen helps prevent alveolar collapse, as it doesn't cross over capillary membranes.

-High levels of oxygen dilute the nitrogen in the lungs leading to alveolar collapse. -Nitrogen helps prevent alveolar collapse, as it doesn't cross over capillary membranes. Nitrogen, which is 79% of room air, helps to prevent alveolar collapse because it doesn't cross over the capillary membranes into the blood. High levels of oxygen administration dilute the nitrogen when it diffuses across the membrane into the circulation, and the alveoli collapse, leading to atelectasis. Oxygen administration can cause toxicity and must be monitored closely. An increased Paco2 will result when the client is retaining CO2; this is not a desirable state. Pao2 levels of greater than 90 mm Hg should be reported to the health care provider.

A client has been receiving 60% oxygen per simple facemask since admission 3 days ago. Which initial findings alert the nurse to oxygen toxicity? Select all that apply. 1 Nonproductive cough 2 Hemoptysis 3 Chest pain 4 High-grade fever 5 Bradycardia 6 Gastrointestinal (GI) upset

-Nonproductive cough -Chest pain -Gastrointestinal (GI) upset Initial symptoms of oxygen toxicity include dyspnea, nonproductive cough, chest pain beneath the sternum, and GI upset. Hemoptysis would be a later symptom as the condition worsens. Bradycardia and fever are not present with oxygen toxicity.

The spouse of a client who is scheduled for a tracheostomy is expressing concern regarding the surgery's impact on their quality of life. What should the focus of the nurse be at this time? 1 Teaching about the techniques explained previously for tracheostomy care 2 Providing information about how to perform emergency resuscitation 3 Emphasizing just getting through the surgery and postoperative period 4 Addressing approaches for the client to communicate with the tracheostomy

Addressing approaches for the client to communicate with the tracheostomy Various methods of nonverbal communication should be tried to determine the best approach to allow the couple to discuss their concerns and approaches for maintaining quality of life. Although it is important for the spouse to learn tracheostomy care and emergency procedures like resuscitation, concern for quality of life will potentially interfere with mastery of the content and skills.

A client with chronic obstructive pulmonary disease (COPD) has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN? 1 Adjust the position of the oxygen tubing. 2 Assess for signs and symptoms of hypoventilation. 3 Change the O2 flow rate to keep SpO2 as prescribed. 4 Choose which O2 delivery device should be used for the client

Adjust the position of the oxygen tubing. The scope of a nursing assistant's work includes positioning of oxygen tubing for client comfort. Assessing for signs and symptoms of hypoventilation, choosing which O2 delivery device to use, and changing the O2 flow rate are actions that are beyond the scope of practice for unlicensed personnel.

A client who has thick, sticky respiratory secretions requires high-flow, humidified oxygen delivery. Which oxygen delivery equipment does the nurse use for this client? 1 Aerosol mask 2 Face tent 3 Nonrebreather mask 4 Venturi mask

Aerosol mask An aerosol mask is used when high humidity is needed, as with thick secretions. A face tent is used for clients with burns or facial trauma. A nonrebreather mask is a low-flow oxygen delivery system. The Venturi mask is not the best method to deliver high-humidity oxygen.

The primary health care provider has written an order to resume the diet for a client with a tracheostomy following a laryngectomy. What does the nurse include when teaching the client about prevention of aspiration? 1 Raise the head of the bed 30 degrees when eating. 2 When swallowing, raise the chin as though looking at the ceiling. 3 All liquids will need to be thickened, including water. 4 If not already inflated, inflate the tube cuff when eating or drinking.

All liquids will need to be thickened, including water. Thickening all liquids gives the client more control over aspiration when swallowing. The client should be sitting upright when eating, and should tuck the chin down and lower the forehead while swallowing to prevent aspiration. Due to the close proximity of the cuffed tube to the esophagus, it may interfere with the passage of food; the cuff should therefore be deflated to facilitate swallowing and prevent aspiration.

Which client has the most urgent need for frequent nursing assessment? 1 An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask 2 A young client who has had a tracheostomy for 1 week, who is on room air with SpO2 at percents in the upper 90s, who has been receiving antibiotic therapy for 16 hours, and who has foul-smelling drainage on the tracheostomy ties 3 An older adult client who is anxious to go home with her new tank of oxygen and supply of nasal cannulas and is being discharged with a new prescription for home oxygen therapy 4 A middle-aged client who was admitted yesterday with pneumonia and is receiving oxygen at 2 L/min through a nasal cannula

An older adult client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask The older adult with a long history of smoking and chronic lung disease is at elevated risk for respiratory depression owing to the hypoxic drive of respirations countered by high levels of oxygen; this client must be assessed frequently while receiving high-flow oxygen. The young client with no signs or symptoms of respiratory compromise, and the client who meets discharge criteria do not require frequent assessment. Although the middle-aged client with pneumonia will require more frequent assessment than a client who does not require oxygen therapy, the older client on higher-flow oxygen is at greater risk for respiratory demise and therefore needs frequent assessment more urgently.

During shift report, the nurse learns the assigned client with chronic lung disease is receiving oxygen at 4 L/min per nasal cannula. When entering the client's room, what is the nurse's initial action? 1 Reduce the rate of oxygen to 3 L/min. 2 Assess oxygen saturation with a pulse oximeter. 3 Request an order for arterial blood gases. 4 Auscultate the lung sounds.

Assess oxygen saturation with a pulse oximeter. A client with chronic lung disease and hypercarbia loses sensitivity to elevated carbon dioxide levels as a stimulus for breathing. Instead, low oxygen levels become the primary stimulus. Clients with hypercarbia and hypoxemia usually require 1-2 L/min (no more than 2-3 L/min) to keep them from losing their hypoxic drive and developing oxygen-induced hypoventilation. In a client receiving 4 L/min, oxygen-induced hypoventilation may be a concern, although inadequately treated hypoxemia is a greater priority. The lowest level of oxygen needed to maintain adequate oxygenation should be given. The nurse should evaluate oxygen saturation with a pulse oximeter before making a decision to reduce the O2 rate or requesting an order for ABGs. Auscultating lung sounds does not provide definitive assessment data on oxygenation.

The peak pressure alarm is sounding on the ventilator of a client with a recent tracheostomy. What intervention should be done first? 1 Assess the client's respiratory status. 2 Decrease the sensitivity of the alarm. 3 Ensure that the connecting tubing is not kinked. 4 Suction the client

Assess the client's respiratory status. The client must always be assessed before attention is turned to equipment. If the alarm is sounding as an indicator of worsening client condition, reducing the sensitivity is harmful. Suctioning the client may not even be needed; the client's respiratory status must be assessed before such a determination can be reached.

A client with an artificial airway is receiving oxygen at a rate of 4 L/min. The nurse notes that a humidifier bottle between the oxygen source and the client is half-full of sterile water and that the water is bubbling. Which action by the nurse is correct? 1 Add water to the humidifier bottle until the water stops bubbling. 2 Change the humidification device to a heated nebulizer. 3 Increase the oxygen flow to 6 L/min to ensure adequate humidification. 4 Remove the humidification device to minimize the risk of infection.

Change the humidification device to a heated nebulizer. All clients receiving oxygen should have humidification to help minimize tissue trauma. Clients receiving oxygen through an artificial airway should have heated humidification to increase the humidity level. If the client were receiving oxygen without an artificial airway, the water would be at an appropriate level and should be bubbling to be effective. Even though humidity increases the risk of infection, the correct action is to follow protocol for changing the equipment to prevent infection.

The nurse discovers that a client's tracheostomy tube has an air leak, and notes a cuff pressure of 20 mm Hg. Which action by the nurse is correct? 1 Contact the provider to request a larger-diameter tracheostomy tube. 2 Inflate the cuff to a pressure of 20-30 mm Hg. 3 Secure the outer cannula of the tracheostomy with tape. 4 Suction the client more often to prevent frequent coughing.

Contact the provider to request a larger-diameter tracheostomy tube. The tracheostomy cuff should be inflated to a pressure of 14-20 mm Hg, or 20-30 cm H2O. If the client continues to show signs of an air leak after properly inflating the cuff, a larger-diameter tube should be used. A range of 20-30 is the range of cm H2O, not mm Hg. Securing the cannula with tape or suctioning the client frequently does not prevent an air leak.

A client with COPD who has been receiving oxygen via nasal cannula is becoming increasingly dyspneic with increased use of accessory muscles to breathe. The nurse auscultates markedly diminished breath sounds in all lung fields. The nurse correctly notifies the provider and discusses which oxygen delivery method for this client? 1 Bi-level positive airway pressure (BiPAP) 2 Continuous positive airway pressure (CPAP) 3 Transtracheal oxygen 4 Venturi mask

Continuous positive airway pressure (CPAP) The client is experiencing atelectasis, as evidenced by diminished breath sounds, and would benefit from CPAP, which helps open alveoli and improve gas exchange. BiPaP is used to improve tidal volume, reduce respiratory rate, and relieve dyspnea. Transtracheal oxygen is used to provide oxygen without the discomfort of a mask or nasal cannula. A Venturi mask helps deliver a precise amount of oxygen, but does not help open alveoli.

When caring for a client with a Venturi mask, one strategy to reduce the fraction of inspired oxygen (Fio2) yet maintain oxygenation is to convert to which device? 1 Nasal cannula 2 Continuous positive airway pressure mask 3 Simple facemask 4 Partial rebreather mask

Continuous positive airway pressure mask The continuous positive airway pressure (CPAP) mask administers continuous positive airway pressure, which increases ventilation by increasing volume and pressure of inhalation. This prevents alveolar collapse, thereby enhancing gas exchange/oxygenation, which would allow for lower Fio2. Other delivery systems do not enhance ventilation.

A client with a cuffed fenestrated tracheostomy tube has been speaking well when the decannulation cap is in place. While visiting, the family alerts the nurse that the client is having difficulty breathing. Which action by the nurse has the highest priority? 1 Calling the health care provider 2 Deflating the cuff 3 Removing the cap 4 Auscultating the breath sounds

Deflating the cuff An inflated cuff with a capped fenestration tube gives the client no airway. Deflating the cuff around the tube will help relieve this. If the client does not improve with cuff deflation, then the cap should be removed. The health care provider should be notified of any further problems. Auscultating breath sounds determines if the tube is in place and might be necessary, but it is not the most important first action.

In a client with a tracheostomy, the nurse notes that the cuff requires increasing amounts of air in order to maintain the seal and observes food particles in the tracheal secretions. Which tracheal complication does the nurse suspect occurred in this client? 1 Dilation 2 Infection 3 Stenosis 4 Obstruction

Dilation Tracheomalacia occurs when the constant pressure from the cuff causes tracheal dilation and erosion of the cartilage. Manifestations of this condition are a need for increasing amounts of air in the tracheal tube cuff, food in tracheal secretions, and failure to receive the full tidal volume delivered by the ventilator. Tracheal infection is characterized by prurulent drainage at the stoma site, along with redness, pain, and swelling. Tracheal stenosis involves scar formation caused by tracheal tube pressure and is usually observed after the tracheostomy tube is removed when stridor, difficulty breathing and swallowing, and coughing occur. Tracheal obstruction is characterized by an inability to move air in and out of the lungs.

A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first? 1 Auscultate the client's breath sounds while applying a nasal cannula. 2 Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask. 3 Apply a 100% non-rebreather mask while administering high-flow oxygen. 4 Replace the obturator while reinserting the tracheostomy tube.

Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask. Because a fresh tracheostomy stoma will collapse, the client will lose airway patency, which will require the nurse to ventilate the client through the mouth and nose while waiting for assistance to recannulate the client. Directing someone else to call the Rapid Response Team allows the nurse to provide immediate care required by the client. Auscultation of the client's breath sounds at this time will not improve the client's respiratory status and will be ineffective until airway patency is restored. Further, auscultation should not be done while a nasal cannula is simultaneously applied. Effective use of a 100% non-rebreather mask requires a patent airway. During the first 72 hours following a tracheostomy, reinsertion of the tube is difficult and should not be attempted by the nurse. Reinsertion of the tracheostomy tube should be done once a Rapid Response Team is available to accomplish this.

A "do not resuscitate" (DNR) client has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first? 1 Ensure that the tubing is patent and that oxygen flow is high. 2 Notify the chaplain and the family member of record. 3 Call the Rapid Response Team and prepare to intubate. 4 Comfort the client and confirm that signed DNR orders are in the chart.

Ensure that the tubing is patent and that oxygen flow is high. Labored breathing and ultimately suffocation can occur if the reservoir bag on a non-rebreather mask kinks, or if the oxygen source disconnects or is not set to high flow levels. The chaplain and the family member of record should not be notified, because death is not imminent at this time. Equipment malfunction must be ruled out before intubation of the client is performed. Additionally, the client may not want to be intubated, as indicated in the DNR orders. Troubleshooting and reversal of nonresuscitative equipment is the standard of care; DNR does not mean "do not treat."

The nurse is preparing a client with a permanent tracheostomy to be discharged home. While providing teaching, the nurse notes that the client's secretions are thick and sticky. What does the nurse include in this client's teaching? 1 Increase daily fluid intake until secretions are thinner and easily mobilized. 2 Instill normal saline drops into the tracheostomy several times daily. 3 Suction the tracheostomy tube frequently to keep the airway clear. 4 Take an over-the-counter expectorant to help clear thickened secretions.

Increase daily fluid intake until secretions are thinner and easily mobilized. Thick and sticky mucus indicates that the client is inadequately hydrated and the fluid intake should be increased. Normal saline drops are sometimes used with questionable benefit and should only be administered if the provider orders them. Suctioning the tracheostomy may increase secretions because of localized irritation to the airway. Over-the-counter expectorants will not help with dehydration.

A client with a tracheostomy is receiving feedings via a nasogastric tube, during which the client experiences increased coughing and choking. The nurse notes that the tracheostomy cuff requires increasing amounts of air to maintain the seal, and when suctioning the tracheostomy, food particles are present in the tracheal secretions. After notifying the provider of these observations, which procedure does the nurse expect to be performed? 1 Insertion of a fenestrated tracheostomy tube. 2 Placement of a jejunostomy tube. 3 Reintubation with a larger tracheostomy tube. 4 Tracheal dilatation in the operating room

Insertion of a fenestrated tracheostomy tube. This client has signs of a tracheoesophageal fistula (TEF) where excessive cuff pressure causes an erosion of the posterior wall of the trachea and into the anterior esophagus. Clients who develop this should either be fed with a very small-bore feeding tube or should have surgical placement of a gastrostomy or jejunostomy tube. A fenestrated tracheostomy tube is used to facilitate coughing or speaking. Placing a larger tracheostomy tube will increase pressure on the tracheal wall. The trachea does not need to be dilated.

A client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first? 1 Suction as needed. 2 Clean the tracheostomy inner cannula and stoma. 3 Listen to lung sounds. 4 Change the tracheostomy dressing as needed.

Listen to lung sounds. The first nursing action for a client following an airway procedure is to assess the client's respiratory status; this requires auscultation of the lungs. Suction is not needed if the lungs are clear to auscultation. Although cleanliness is a priority, the nurse must assess the client's respiratory status before cleaning or performing a dressing change.

Which technique or action does the nurse use to prevent a tracheoesophageal fistula (TEF) in a client after a tracheotomy has been performed? 1 Manually administer oxygen by mask. 2 Maintain proper cuff pressure. 3 Prevent pulling or tugging on the tube. 4 Apply direct pressure to the stoma site.

Maintain proper cuff pressure. A TEF is a hole created between the trachea and the anterior esophagus due to excessive cuff pressure. Three methods of preventing this complication are to progress to a deflated cuff or cuffless tube as soon as possible, maintain proper cuff pressure, and monitor the amount of air needed for inflation for any change. Manually administering oxygen by mask is an appropriate intervention once the fistula has formed, but it does not prevent the formation. Applying direct pressure is an intervention for a trachea-innominate artery fistula.

A client's family is asking about the comparative risks with a ventilator versus noninvasive positive pressure ventilation (NPPV). Which principle should guide the nurse's response? 1 A ventilator is preferred; it will be required if the problem is dyspnea or hypercarbia. 2 The positive pressure aspect of NPPV will provide for the client's current oxygenation. 3 The client most likely requires positive end-expiratory pressure (PEEP), and would need a ventilator for adequate response. 4 NPPV should be used only in clients with intact mental status who can protect their airway.

NPPV should be used only in clients with intact mental status who can protect their airway. Both the ventilator and NPPV have advantages and risks. A major concern in clients on NPPVs is that they must be alert enough to protect their own airway; mental status would be a key determining factor. Either system can be used to treat dyspnea or hypercarbia. The need for PEEP is not known at this time.

When providing suctioning through an endotracheal or tracheostomy tube, what alerts the nurse to stop suctioning? 1 Oxygen saturation by pulse oximetry is less than 90%. 2 The client coughs uncontrollably during suctioning. 3 Secretions are thick and occluding the suction catheter. 4 The client's heart rate increases from 72 to 78.

Oxygen saturation by pulse oximetry is less than 90%. Oxygen saturation below 90% indicates hypoxemia and is a reason to stop suctioning. The cough reflex is an expected response to suctioning; it does not preclude the necessity to clear the airway, although excessive coughing would prompt the nurse to allow the client to rest. The suction catheter can be irrigated to empty thick secretions and restore suction. An increased heart rate from 72 to 78 is not substantial to cause concern.

The nurse is discharging a client with a prescription for continuous oxygen therapy via nasal cannula at home. What does the nurse include in the discharge teaching? 1 Pad the tubing behind the ears. 2 No family members or visitors may smoke within three feet of the client. 3 Petroleum jelly (Vaseline) may be applied to dry nostrils and chapped lips. 4 Provide mouth care daily.

Pad the tubing behind the ears. Because the tubing creates pressure that may lead to skin breakdown (especially behind the ears), padding the tubing prevents this complication. Smoking is prohibited in a room where oxygen therapy is being administered. Petroleum jelly is flammable and should not be used on the client's face, nose, or lips; a nonpetroleum cream should be used.

The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period? 1 Computer keyboard 2 Magic Slate 3 Picture board 4 Pen and paper

Picture board A picture board does not require very much dexterity for communication. Dexterity can be limited to the extent the client finds comfortable. A computer keyboard, Magic Slate, and pen and paper require dexterity that may be difficult and/or painful for a client with degenerative arthritis.

The risk of aspiration during oral intake with a tracheostomy is related to which factor? 1 Presence of a pressurized cuff on the tracheostomy tube 2 Proximity of the tracheostomy tube to the epiglottis 3 Ability of the client to be able to speak clearly 4 Amount of xerostomia experienced by the client

Proximity of the tracheostomy tube to the epiglottis Due to the normal close proximity of the trachea and the esophagus, a tracheostomy tube can potentially interfere with protecting the airway during swallowing. A pressurized cuff on a tracheostomy tube doesn't provide assurance against aspiration during swallowing. Although xerostomia will make eating more challenging, it doesn't directly cause an increased risk of aspiration.

Respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse? 1 Humidifying the oxygen source 2 Increasing oxygenation 3 Removing the inner cannula of the tracheostomy 4 Suctioning the client

Suctioning the client Suctioning the client will likely result in clear lung sounds and lower peak pressure, and the appearance of the sputum will indicate whether bleeding is a concern. Humidifying the oxygen source will help mobilize secretions, but an active cough response is also required to clear the airway; a sedated client has a weak cough. Increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. Removing the inner cannula of a ventilated client is contraindicated.

When the inner cannula is removed from a fenestrated tracheostomy tube, what is an expected client function? 1 The client is able to swallow small sips of water. 2 Full range of motion of the neck will be restored. 3 The client will be able to speak. 4 The client will be able to expectorate secretions more effectively.

The client will be able to speak. A fenestrated tube has holes that allow air to pass during exhalation through the vocal cords, enabling speech. Removing the inner cannula enables this feature. The client is at risk for aspiration until determined to be safe with a swallow study, so removal of the inner cannula does not mean it is safe to sip water. Removal of the inner cannula does not affect range of motion of the neck nor the client's ability to cough more effectively.

A client has developed subcutaneous emphysema after surgery for a tracheostomy. Why must the nurse notify the health care provider immediately? 1 The client has a pneumothorax and will require a chest tube for decompression. 2 Ventilator pressures are too high, forcing air into tissue, and must be lowered. 3 Bleeding has occurred related to the surgical incision; hemoglobin is low. 4 There is an opening or tear in the trachea allowing air leakage into the tissues.

There is an opening or tear in the trachea allowing air leakage into the tissues. Subcutaneous emphysema occurs when there is an opening or tear in the trachea adjacent to the tracheostomy, allowing air to leak into the surrounding tissues. Air can also progress throughout the chest and other tissues into the face. This requires immediate action to maintain adequate oxygenation. A pneumothorax may occur in the apex of the lung; however, this is not likely to cause subcutaneous emphysema. When ventilator pressures are too high, lung damage may occur from this, rather than from subcutaneous emphysema. Some bleeding after surgery is not abnormal, and the incision area should be monitored for hematoma, leakage, or evidence of bruising; this is not related to the subcutaneous emphysema.

Immediately after having a tracheostomy tube removed as ordered by the provider, the client begins to cough and has difficulty breathing, talking, and clearing secretions. After notifying the provider, the nurse anticipates an order for which procedure? 1 Insertion of an oral airway 2 Placement of a nasogastric tube 3 Reintubation 4 Tracheal dilation

Tracheal dilation This client shows signs of tracheal stenosis characterized by increased cough, difficulty breathing and talking, and decreased ability to clear secretions. Tracheal dilation is usually necessary to open the trachea. Insertion of an oral airway does not open the trachea. Placement of a nasogastric tube is not indicated. Reintubation will make the tracheal stenosis worse.

A client who has been receiving high-flow oxygen via a Venturi mask for several days is reporting respiratory difficulty and that the mask doesn't seem right. What cause could be contributing to this sensation? 1 The rebreather bag on the mask has water accumulated in it, thus decreasing the volume of oxygen available. 2 The flaps over the exhalation ports on the nonrebreather bag are not opening and closing as the client breathes. 3 When the mask was changed at the end of the previous shift, a simple facemask was initiated for oxygen delivery. 4 The mask now being used is too large for the client's face.

When the mask was changed at the end of the previous shift, a simple facemask was initiated for oxygen delivery. The Venturi mask is for high-flow oxygen therapy; if it was switched to a simple facemask, the client would likely notice the difference in oxygen delivery. A Venturi mask does not have a rebreather bag or a nonrebreather bag. The reported problem is most likely related to not using a high-flow oxygen delivery system, rather than the size of the mask.