Ch. 25

What is the nurse's best response when a client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck?" "But you know you need this to breathe, right?" "The hole can be hidden with a light scarf." "Your family and those who love you won't care." "It won't take you long to learn to manage."

"The hole can be hidden with a light scarf." The nurse's best response is to suggest some strategies to cover the tracheostomy. This statement recognizes the client's concerns and explores options for dealing with the effects of the procedure.Reiterating the reason for the tracheostomy, suggesting that the client's loved ones won't care, and telling the client that he or she will learn to live with the tracheostomy are insensitive responses and minimize the client's concerns.

Which statement made by a client prescribed oxygen therapy at home indicates to the nurse that more instruction is needed? A. "When I want to smoke, I will use the liquid oxygen reservoir instead of the compressed oxygen tank." B. "Using oxygen should help me have more breath and stamina when I eat, bathe, and take care of myself." C. "Even though they contain alcohol, I can still drink a glass of wine or can of beer while using oxygen." D. "If my shortness of breath becomes worse or if I have chest pain I will contact my primary health care provider immediately."

A

Which conditions or changes indicate to the nurse that a client with a tracheostomy requires suctioning? Select all that apply. A. The client has a fever. B. Crackles and wheezes are heard on auscultation. C. The client requests that suctioning be performed. D. Suctioning was last performed more than 3 hours ago. E. The tracheostomy dressing has a moderate amount of serosanguineous drainage. F. The skin around the tracheostomy is puffy and makes a crunching sound when touched.

BC

The SpO 2 of a client receiving oxygen therapy by nasal cannula at 6 L/min has dropped from 94% an hour ago to 90%. Which action does the nurse perform first to improve gas exchange before reporting the change to the primary health care provider? A. Tighten the straps on the nasal cannula B. Increase the oxygen flow rate to 8 L/min C. Check the tubing for kinks, leaks, or obstructions D. Check to determine whether the oxygen delivery system is adequately humidified

C

Which action does the nurse take care to avoid while suctioning a client's tracheostomy tube? A. Twirling the catheter while applying suction B. Applying suction only when withdrawing the catheter C. Performing oral suctioning before suctioning the artificial airway D. Lubricating the suction catheter with sterile saline before insertion

C

Which changes in a client receiving oxygen therapy at 60% for more than 24 hours alert the nurse to the possibility of oxygen toxicity? Production of thick, white, frothy sputum Client demand to remove the mask Client report of increased dyspnea Decreased PaCO2

Client report of increased dyspnea Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane, and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic. The PaCO2 would increase, not decrease. The production of thick, frothy, white sputum is unrelated to oxygen toxicity. The client's demand to remove the mask is not specific to oxygen toxicity.

Which action does the nurse use to prevent harm by loss of tracheal tissue integrity in a client with a tracheostomy? A. Providing meticulous oral care every 8 hours B. Deflating the cuff for 15 minutes every 2 hours C. Feeding the client liquids rather than solid foods D. Maintaining cuff inflation pressure less than 25 cm H2O

D

Which manifestations in a client receiving oxygen therapy at 60% for more than 24 hours alerts the nurse to the possibility of oxygen toxicity? A. Oxygen saturation greater than 100% B. Decreased rate and depth of respiration C. Wheezing on inhalation and exhalation D. Discomfort or pain under the sternum

D Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic. Initial manifestations include dyspnea, nonproductive cough, chest pain beneath the sternum, and gastrointestinal upset. Oxygen saturation falls, not increases. Breathing becomes more rapid with the sensation of dyspnea. Wheezing represents airway obstruction, not damage to the alveolar membrane.

A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8 weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder? Thyroid cancer Acute laryngitis Laryngeal cancer Bronchogenic cancer

Laryngeal cancer Hoarseness is a common early sign of laryngeal cancer, but not of thyroid or bronchogenic cancer. Hoarseness that persists for 8 weeks is not associated with an acute problem, such as laryngitis.

Which actions will the nurse take to reduce risk for aspiration for a client with a tracheostomy? (Select all that apply.) Encouraging frequent sipping from a cup Encouraging water with meals Inflating the tracheostomy cuff during meals Maintaining the client upright for 30 minutes after eating Providing small, frequent meals Teaching the client to "tuck" the chin down in the forward position to swallow

Maintaining the client upright for 30 minutes after eating Providing small, frequent meals Teaching the client to "tuck" the chin down in the forward position to swallow Interventions that must be noted in the client's plan of care include having the client remain upright for at least 30 minutes after eating to reduce the chance of aspiration. Also, making sure that small frequent meals are available for the client. Shorter and more frequent intervals of eating tire the client less and also reduce the chance for aspiration. Teaching the client how to tuck the chin down in the forward position helps to open the upper esophageal sphincter and again reduces the risk of aspiration.Sipping from a cup is contraindicated. Liquids are consumed using a spoon to ensure that the client is attempting to swallow only small volumes of liquid. Controlled small amounts of thickened liquids are given. Thin liquids such as water should be avoided because they are easily aspirated. The tracheostomy cuff needs to be deflated because an inflated tube narrows the upper esophageal sphincter opening, which increases the risk for aspiration.

Which nursing action will the nurse take to prevent harm from disruption of oxygen therapy for the client receiving low-flow oxygen by simple facemask? Changing to a nasal cannula during meals Ensuring that the flaps are closed over the exhalation ports Sealing the edges of the mask to the client's skin with a water-soluble lubricant. Keeping a small cylinder of oxygen at client's bedside stand for emergency use in case the central oxygen delivery system fails

Changing to a nasal cannula during meals The facemask covers the client's mouth and must be removed during meals. Use of the nasal cannula when the client eats prevents hypoventilation or hypoxemia from the facemask being of during mealtimes.Sealing the mask does not ensure disruption of oxygen therapy. A simple facemask does not have flaps over the exhalation ports. Central oxygen delivery system failure is a unit or facility problem that could happen anywhere; however, tank oxygen is not kept at clients' bedsides for this potential emergency.

Which assessment finding for a client receiving oxygen therapy with a nonrebreather mask requires the nurse to intervene immediately? A. The oxygen flow rate is set at 12 L/min. B. The exhalation ports are open during exhalation. C. The exhalation ports are closed during inhalation. D. The reservoir bag is not inflated during inhalation.

D

What action does the nurse take first when a client who has a "do not resuscitate" (DNR) order and a nonrebreather oxygen mask, has labored breathing? Ensure that the tubing is patent and that oxygen flow is high. Notify the chaplain and the family member of record. Initiate the Rapid Response Team (RRT). Only provide comfort to the client.

Ensure that the tubing is patent and that oxygen flow is high. The nurse needs to first ensure that the tubing is patent and that the O2 flow is high. Labored breathing and ultimately suffocation can occur if the reservoir bag on a nonrebreather mask kinks, or if the oxygen source disconnects or is not set to high-flow levels.The chaplain and the family member of record would not be notified until assessment confirms that death is imminent at this time. The RRT team can be called but the client may not want to be intubated, as indicated in the DNR orders. The RRT needs to know the client's wishes when they arrive. Comforting the client must be done but is not the first action by the action.

For which problem in a client with a tracheostomy will the nurse collaborate with the speech-language pathologist (SLP) member of the interprofessional team? Assessing for vocal cord damage Ensuring effective communication Determining the proper cuff pressure Identifying early indications of infection

Ensuring effective communication One of the many roles of the SLP is helping health care professionals work with clients who have communication problems to find the most effective means of maintaining communication. They also may be involved in assessing clients for aspiration risk. They are not involved in vocal cord assessment (primary health care provider responsibility), infection assessment, or determining correct cuff pressure (respiratory therapist responsibility).

Which oxygen delivery device will the nurse consider best to meet the needs to apply for a newly admitted client who requires high-flow oxygen therapy after suffering facial burns and smoke inhalation? Face tent Venturi mask Nasal cannula Nonrebreather mask

Face tent The nurse will initially select a fact tent for this client. A client with smoke inhalation and facial burns who requires high-flow oxygen must initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue.Although a Venturi mask and a nonrebreather mask are high-flow oxygen delivery devices, they are snugly fitted on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device.

Which best practice technique will the nurse use when suctioning a client's tracheostomy tube place earlier today? Hyperoxygenating the client before and after suctioning Suctioning repeatedly until the secretions are is clear Applying suction only during insertion of the catheter Ensuring each suction pass lasts no longer 30 seconds

Hyperoxygenating the client before and after suctioning The client needs to be preoxygenated/hyperoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client needs to be hyperoxygenated for 1 to 5 minutes, or until the client's baseline heart rate and oxygen saturation are within normal limits.Repeat suctioning can be performed as needed for up to three total suction passes. Any additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult and is traumatic to the airway. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; a suction pass should last 10 to 15 seconds.

What is the nurse's best first action when a client receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused? Repositioning the client from a high-Fowler to a low-Fowler position Notifying the primary health care provider immediately Documenting the observation as the only action Increasing the oxygen flow rate

Increasing the oxygen flow rate Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen and action is needed. Untreated or inadequately treated hypoxemia is life threatening. Although you would want to notify the health care provider of the change in the client's condition, the best action is to first increase the oxygen flow rate and then notify the physician.Changing the client's position to less upright, would not improve gas exchange.

Which assessment has the highest priority for the nurse to make when caring for a client who had a tracheostomy placed yesterday? Which of these assessments is essential for the nurse to make? Observing for tachypnea Measuring the cuff pressure Checking arterial blood gas values Examining the color and consistency of secretions

Observing for tachypnea It is essential for the nurse to assess the client for tachypnea. Tachypnea can indicate hypoxia.Assessing secretions, checking arterial blood gas values, and measuring cuff pressure are all appropriate interventions, after assessing airway and breathing.

For which situation will the nurse take immediate action to prevent harm for a client with pneumonia who is receiving 100% oxygen via a nonrebreather mask? Skin is pink and flushed. Sputum is now rust-colored. Crackles are present in the lung bases. Oxygen reservoir deflates during inspiration.

Oxygen reservoir deflates during inspiration. The nurse takes action immediately if the reservoir bag is deflated. Suffocation can occur if the reservoir bag deflates, kinks, or if the oxygen source disconnects. The nurse needs to remove the device, refill the reservoir, and then reapply the mask.It is anticipated that the client's color is now pink. The client's color is expected to improve (from ashen or gray to pink) because of an increase in PaO2 level. Crackles in lung bases are an expected finding in a client with pneumonia, as is expectorating rust-colored sputum.

Which change in the condition of a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen indicates to the nurse that an increase in the fraction of inspired oxygen (FiO2) may need to be increased? Client reports increased mouth dryness. Restlessness has increased over the past hour. Heart rate has decreased from 90 to 82 beats/min. Blood pressure has changed from 106/80 to 110/70.

Restlessness has increased over the past hour. The nurse needs to assess the client who has recently become restless for the need to increase this client's FiO2. This client may be exhibiting symptoms of hypoxemia including restlessness. Additional symptoms of hypoxemia include increased heart rate and blood pressure, oxygen desaturation, cyanosis, restlessness, and dysrhythmias.A heart rate decrease to 82 beats/min and not cause for alarm or a change in FiO2. The change in blood pressure is a positive indicator of reasonable perfusion and gas exchange. Mouth dryness is not an indicator of poor gas exchange and the need for more oxygen.

Which action will the nurse take to prevent harm from tracheal stenosis in a client after tracheostomy? Ensuring maximum cuff pressure Securing the tube in a midline position Assessing bilateral breath sound every 2 hours Using commercial tube holders instead of standard tracheostomy ties

Securing the tube in a midline position Tracheal stenosis, a narrowed tracheal lumen, is caused to scar tissue formation from irritation. Two methods of preventing this complication is to keep the tube from moving in the trachea and to maintain proper cuff pressure. Securing the tube in the midline position is critical regardless of whether the tube is secured with commercial tube holders or standard tape ties. Although assessing breath sounds bilateral is an important action whenever a client has a tracheostomy, but does not prevent harm from tracheal stenosis.

The nurse is caring for a client with a newly placed tracheostomy. Which emergency equipment should be available at the bedside? Select all that apply. Tongue blade Endotracheal tube Tracheostomy tube Tracheostomy insertion tray Manual resuscitation bag with face mask

Tracheostomy tube Tracheostomy insertion tray Manual resuscitation bag with face mask Rationale: When a new tracheostomy is placed, the nurse must plan for accidental dislodgement. Emergency equipment at the bedside would include an additional tracheostomy tube, an emergency tracheostomy tray (in case of difficulty placing the new tracheostomy), and a manual resuscitation bag with a face mask to ventilate the client during tube replacement. Options 1 and 2 are not necessary equipment for the client with a newly placed tracheostomy.

What is the nurse's best response to a client who smokes and is being discharged home on oxygen states, "My lungs are already damaged, so I'm not going to quit smoking?" "For safety, lower your oxygen flow rate when you smoke." "Tell me more about why you think quitting wont's help you." "For now, let's discuss why smoking around oxygen is dangerous." "The progression to damage to your lungs can be slowed if you stop smoking now."

"For now, let's discuss why smoking around oxygen is dangerous." The nurse's best response is to ask the client to discuss why smoking around oxygen is dangerous. The nurse would use this opportunity to educate the client about the dangers of smoking in the presence of oxygen. Although knowing the benefits of quitting smoking could be helpful for this client, safety is the most important issue at this time. Decreasing the oxygen flow rate while smoking still poses a safety risk.

Which statements made by a client going home with a tracheostomy indicate to the nurse the need for further teaching about correct tracheostomy care? (Select all that apply.) "I can only take baths, but no showers." "I can put normal saline in my tracheostomy to keep the secretions from getting thick." "I should put cotton or foam over the tracheostomy hole." "I will have to learn to suction myself." "I will be unable to wear a necklace." "I will notify my primary health care provider if my secretions develop a foul odor."

"I can only take baths, but no showers." "I can put normal saline in my tracheostomy to keep the secretions from getting thick." "I should put cotton or foam over the tracheostomy hole." "I will be unable to wear a necklace." Need for teaching is indicated when the client says that only baths and no showers can be taken. The client is permitted to shower with the use of a shower shield over the tracheostomy, which prevents water from entering the airway. Also, the client does not instill anything into the artificial airway unless prescribed. The client would not put cotton or foam over the tracheostomy hole; this action may cause airway obstruction. The stoma may be covered loosely with a small cotton cloth or light scarf to protect it during the day. This filters the air entering the stoma, keeps humidity in the airway, and enhances appearance.The client is correct when commenting about learning to suction self, and will be taught clean suction technique to use at home. Also, foul-smelling secretions or drainage indicates possible infection and needs to be reported to the primary health care provider.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A 45 year old who is being discharged with a new prescription for home oxygen therapy by nasal cannula. A 50 year old who is 1 day postoperative from abdominal surgery and is receiving 2 L oxygen by nasal cannula. A 55 year old was admitted yesterday with pneumonia and is receiving antibiotics and oxygen through a nasal cannula. A 60 year old admitted 2 hours ago who has a 90-pack-year smoking history and is receiving 50% oxygen by Venturi mask.

A 60 year old admitted 2 hours ago who has a 90-pack-year smoking history and is receiving 50% oxygen by Venturi mask. There is insufficient data to determine if this client is stable. The client is at risk for oxygen toxicity and must be assessed frequently.The postoperative client is receiving the low oxygen therapy typical for anyone having postoperative therapy who has no other respiratory problems. The client who meets discharge criteria does not require frequent assessment. Although the client with pneumonia will require more frequent assessment than a client who does not require oxygen therapy, the client wearing the Venturi mask must be assessed first.

The nurse knows that an inflated cuff for a tracheostomy is indicated for which client? Select all that apply. A client at risk for aspiration A client who is physically dependent A client who needs to be able to speak A client who requires mechanical ventilation A client who requires assistance with activities of daily living

A client at risk for aspiration A client who requires mechanical ventilation Rationale: For clients who require a tracheostomy, the primary health care provider may choose to use an inflated cuff. This is indicated for clients who are at risk for aspiration and who require mechanical ventilation. Inflated cuffs exert pressure on the tracheal mucosa. Inflated cuffs cannot be used for clients who need to speak; a fenestrated-type of cuff needs to be used in order for the client to be able to speak. A client who is physically dependent and who requires assistance with activities of daily living are not indications for this type of cuff.

Which problem does the nurse suspect when a client who has been receiving 50% oxygen by Venturi mask for 2 days now has crackles and decreased breath sounds on auscultation? Absorptive atelectasis Bronchiolar infection New-onset asthma Stasis pneumonia

Absorptive atelectasis Absorptive atelectasis occurs when high oxygen levels are delivered that causes nitrogen dilution when oxygen diffuses from the alveoli into the blood. The alveoli collapse, which is detected as crackles and decreased breath sounds on auscultation. The problem is in the alveoli, not the airways. Although decreased breath sounds accompany pneumonia, crackles are not present with the increased density.

Which action will the nurse take first when a client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure? Which nursing action must be taken first? Auscultating lung sounds Observing for indications that suctioning is needed Cleaning the tracheostomy inner cannula and stoma Changing the tracheostomy dressing immediately

Auscultating lung sound The first step of the nursing process and nursing action for a client following an airway procedure is to assess for a patent airway by auscultating the client's lungs and assessing the client's respiratory status.Suction is not needed if the lungs and airways are clear to auscultation. Although cleanliness is important, the PACU nurse will not typically perform this procedure immediately after the tracheotomy is created, unless copious secretions are blocking the tube.Performing a dressing change is done every 8 hours or per hospital policy. The PACU nurse will perform this if the dressing is soiled or bloody, but assessment of airway must be performed first.

Which statements about oxygen and oxygen therapy are true? Select all that apply. A. An oxygen concentrator reduces the amount of carbon dioxide in atmospheric air. B. Clients must provide informed consent to receive oxygen therapy. C. Excessive oxygen use is a contributing cause of chronic obstructive pulmonary disease. D. In nonemergency situations, a health care provider's prescription is needed for oxygen therapy. E. Oxygen can explode when handled improperly. F. Oxygen is a beneficial element but can harm lung tissue. G. The liquid form of oxygen is a drug to manage hypoxia, whereas the gaseous form is only an atmospheric element. H. Unless humidity is added, therapy with oxygen dries the upper and lower mucous membranes.

CDFH

Which statements regarding noninvasive positive-pressure ventilation (NPPV) are true? (Select all that apply.) Can only be used safely by alert clients. Masks must have a tight seal for effective ventilation. An endotracheal tube is required for oxygen therapy. Vomiting with potential aspiration can occur. The system operates with either room air or oxygen. Risk for ventilator-associated pneumonia is reduced but still present.

Can only be used safely by alert clients. Masks must have a tight seal for effective ventilation. Vomiting with potential aspiration can occur. The system operates with either room air or oxygen. The NPPV technique uses positive pressure to keep alveoli open and improve gas exchange without the dangers of intubation, such as ventilator-associated pneumonia. NPPV can deliver oxygen or may use just room air. Masks must fit tightly to form a proper seal. Pressure can cause gastric insufflation, which can lead to vomiting and the potential for aspiration. Thus, NPPV is recommended only for use with on alert patients who have the ability to protect their airway.

The nurse is suctioning a client who has an endotracheal tube in place. Which finding indicates that the client is experiencing an adverse effect of this procedure? Cardiac irregularities Oxygen saturation level of 95% A reddish coloration in the client's face Apical pulse rate of 80 beats per minute

Cardiac irregularities Adverse effects of suctioning include hypoxemia, cardiac irregularities caused by vagal stimulation, mucosal trauma, and paroxysmal coughing. If these occur during the procedure, the procedure is stopped and the client is reoxygenated. Options 2 and 4 are normal findings. A reddish coloration in the client's face may occur during suctioning but should quickly resolve when the suction catheter is removed from the client.