Chapter 28 questions - Exam 1

A patient is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)? A. Apply water-soluble ointment to nares and lips. B. Periodically turn the oxygen down or off. C. Remove the tubing from the patient's nose. D. Turn the patient every 2 hours or as needed.

A

A patient has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the patient's face is puffy and the eyelids are swollen. What action by the nurse takes priority? A. Assess the patient's oxygen saturation. B. Notify the Rapid Response Team. C. Oxygenate the patient with a bag-valve-mask. D. Palpate the skin of the upper chest.

A

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? A. Applying suction while inserting the catheter B. Preoxygenating the patient prior to suctioning C. Suctioning for a total of three times if needed D. Suctioning for only 10 to 15 seconds each time

A

An unlicensed assistive personnel (UAP) was feeding a patient with a tracheostomy. Later that evening, the UAP reports that the patient had a coughing spell during the meal. What action by the nurse takes priority? A. Assess the patient's lung sounds. B. Assign a different UAP to the patient. C. Report the UAP to the manager. D. Request thicker liquids for meals.

A

A home health nurse is visiting a new patient who uses oxygen in the home. For which factors does the nurse assess when determining if the patient is using the oxygen safely? (Select all that apply.) A. The patient does not allow smoking in the house. B. Electrical cords are in good working order. C. Flammable liquids are stored in the garage. D. Household light bulbs are the fluorescent type. E. The patient does not have pets inside the home.

A, B, C

A nurse is teaching a patient about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the patient? (Select all that apply.) A. Absorptive atelectasis B. Combustion C. Dried mucous membranes D. Oxygen-induced hyperventilation E. Toxicity

A, B, C, E

A nurse is planning discharge teaching on tracheostomy care for an older patient. What factors does the nurse need to assess before teaching this particular patient? (Select all that apply.) A. Cognition B. Dexterity C. Hydration D. Range of motion E. Vision

A, B, D, E

A nurse is caring for a patient who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) A. Applying water-soluble lip balm to the patient's lips B. Ensuring that the humidification provided is adequate C. Performing oral care with alcohol-based mouthwash D. Reminding the patient to cough and deep breathe often E. Suctioning excess secretions through the tracheostomy

A, D

A patient is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the patient maintain self-esteem? (Select all that apply.) A. Create a communication system. B. Don't go out in public alone. C. Find hobbies to enjoy at home. D. Try loose-fitting shirts with collars. E. Wear fashionable scarves.

A, D, E

A nurse is caring for a patient using oxygen while in the hospital. What assessment finding indicates that outcomes for patient safety with oxygen therapy are being met? A. 100% of meals being eaten by the patient B. Intact skin behind the ears C. The patient understanding the need for oxygen D. Unchanged weight for the past 3 days

B

A nursing student caring for a patient removes the patient's oxygen as prescribed. The patient is now breathing what percentage of oxygen in the room air? A. 14% B. 21% C. 28% D. 31%

B

A patient has a tracheostomy tube in place. When the nurse suctions the patient, food particles are noted. What action by the nurse is best? A. Elevate the head of the patient's bed. B. Measure and compare cuff pressures. C. Place the patient on NPO status. D. Request that the patient have a swallow study.

B

A patient is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? A. Administer prescribed anxiolytic medication. B. Ensure that informed consent is on the chart. C. Reinforce any teaching done previously. D. Start the preoperative antibiotic infusion.

B

A patient is wearing a venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? A. Assess the patient's oxygen saturation and, if normal, turn off the oxygen. B. Determine if the patient can switch to a nasal cannula during the meal. C. Have the patient lift the mask off the face when taking bites of food. D. Turn the oxygen off while the patient eats the meal and then restart it.

B

A patient with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis of impaired self-esteem are being met? A. The patient demonstrates good understanding of stoma care. B. The patient has joined a book club that meets at the library. C. Family members take turns assisting with stoma care. D. Skin around the stoma is intact without signs of infection.

B

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? A. Holding the device securely when changing ties B. Suctioning the patient first if secretions are present C. Tying a square knot at the back of the neck D. Using half-strength peroxide for cleansing

C

The nurse assesses the patient using the device pictured below to deliver 50% O2: (It's a pic of a High-Flow Venturi Mask). The nurse finds that the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? A. Assess the patient's oxygen saturation. B. Document these findings in the chart. C. Immediately increase the flow rate. D. Turn the flow rate down to 2 L/min.

C

A nurse is assessing a patient who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the patient's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? A. Call the operating room to inform them of a pending emergency case. B. No action is needed at this time; this is a normal finding in some patients. C. Remove the tracheostomy tube; ventilate the patient with a bag-valve-mask. D. Stay with the patient and have someone else call the provider immediately.

D