Chapter 28: Care of Patients Requiring Oxygen Therapy or Tracheostomy

A client has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar. Which assessment finding requires immediate action by the nurse? a.Constant, nonproductive coughing b.Blood-tinged sputum c.Rhonchi in upper lobes d.Dry mucous membranes

ANS: A Causes and manifestations of lung injury from oxygen toxicity include nonproductive cough, substernal chest pain, GI upset, and dyspnea. Blood-tinged sputum is expected in clients with new tracheostomies. Rhonchi in upper lobes indicates sputum that can be expectorated and is not an emergent problem. Dry mucous membranes should be lubricated, and the client's hydration status can be checked

. The nurse assesses a client with a new tracheotomy, and the tracheostomy tube is pulsating in synchrony with the client's heartbeat. Which is the nurse's priority action? a. Notify the health care provider immediately. b. Stabilize the tube by reapplying the ties. c. Change the inner cannula of the tube. d. Increase the inflation pressure of the cuff.

ANS: A If a tracheostomy tube is pulsating with the client's heart rate, this could indicate proximity to the innominate artery and may cause erosion of the artery if left in this position. The provider should be notified immediately. Reapplying the ties, changing the inner cannula, and increasing the inflation pressure of the cuff are all interventions that will not solve the immediate problem of proximity of the tube to the innominate artery.

A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds the client cyanotic with labored respirations. Which action does the nurse perform first? a.Remove bedding from around the adaptor opening. b.Listen to lung sounds and obtain a respiratory rate. c.Call respiratory therapy to check oxygen saturation. d.Notify the provider or Rapid Response Team immediately.

ANS: A The Venturi mask works by drawing in a specific amount of air to mix with the oxygen through holes in an adaptor fitted at the bottom of the mask. Holes of different sizes allow different amounts of room air to be entrained, changing the amount of oxygen delivered. Bedding (or clothing) wrapped around those holes would effectively change the FiO2. The nurse should ensure that the holes remain unobstructed. Other options are appropriate but are not the first choice, because this simple step may be what solves the problem.

The nurse is teaching a client about his fenestrated tracheostomy tube. Which statement by the client indicates an accurate understanding of the tube? a. "I'm glad I will still be able to talk with this tube in place." b. "It is great that this tube does not have to be cleaned regularly." c. "This tube will not get dislodged because it never needs suctioning." d. "Because I can't swallow, I will need another tube for eating."

ANS: A The client can speak with a fenestrated tube, which has a hole in it and allows air to flow over the vocal cords. The tube still needs to be cleaned and suctioned. The tube may become dislodged, and the client is able to swallow.

. Which interventions help to prevent aspiration during eating for a client with a tracheostomy? (Select all that apply.) a.Provide close supervision for the client during eating and drinking. b.Add liquids to foods to make them thinner and easier to swallow. c.Inflate the tracheostomy cuff tube to maximum pressure before starting. d.Let the client indicate readiness for another bite when being fed. e.Have the client tuck the chin down and forward while swallowing. f.Instruct the client to dry swallow to clear food particles from the throat. g.Place the client in a semi-Fowler's position for an hour after eating.

ANS: A, D, E, F The client with a tracheostomy will require close supervision, even if the client is feeding himself or herself. Do not rush the client. Allow him or her to indicate when ready for another bite. Teaching interventions should include instructing the client to tuck the chin down and forward while swallowing to encourage food to move down smoothly. Dry swallowing helps remove food residue. Food may actually become easier to aspirate if it is thinner in texture. The nurse should not initiate adding air to inflate the cuff of a tracheostomy tube further without a physician's order; if possible, the cuff should be deflated during eating. Placing the client in a semi-Fowler's position after the meal will not prevent aspiration.

A client receiving high-flow oxygen has new crackles and diminished breath sounds since the last assessment 1 hour ago. Which action by the nurse is most appropriate? a. Call respiratory therapy and request a bronchodilator treatment. b. Instruct the client to use the spirometer and to cough and deep breathe. c. Consult with the health care provider and request an order for diuretics. d. Ensure that the ordered FiO2 is what is being provided.

ANS: B A client who is receiving high rates of oxygen is at risk for absorption atelectasis, in which the normal nitrogen in the air becomes diluted and the alveoli collapse. Hallmarks of this condition include new onset of crackles and diminished breath sounds. Spirometer use, coughing, and deep-breathing exercises would help to re-expand the alveoli. None of the other options are appropriate choices.

A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What does the nurse do first? a. Notify the health care provider. b. Assess the client's pulse oximetry. c. Document the observation. d. Raise the head of the bed.

ANS: B Cerebral hypoxia is a cause of confusion and is a sensitive indicator that the client needs more oxygen. Although you would want to notify the provider of the change in the client's condition, the best action is first to assess pulse oximetry and then to increase the oxygen. You would not just document the assessment finding without intervening. Raising the head of the bed would not help the client oxygenate better.

The nurse observes a nursing student suctioning a client. Which intervention by the student nurse requires the supervising nurse to intervene? a. Checking oxygen saturation post suctioning b. Hyperoxygenating the client after removal of the catheter c. Applying intermittent suction during catheter removal d. Applying suction when the catheter is inserted

ANS: D Applying suction as the catheter is introduced allows the tubing to adhere to the airway and destroys cells. The other options are appropriate actions on the part of a nurse or student who is suctioning a client.

A client has been brought in by the rescue squad to the emergency department. The client is having an acute exacerbation of chronic obstructive pulmonary disease (COPD) and is severely short of breath. On arrival, the client is on 15 L/min of oxygen via rebreather mask. Which action by the nurse takes priority? a.Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cannula. b.Perform a thorough respiratory assessment and attach pulse oximetry. c.Call the laboratory to obtain arterial blood gases as soon as possible. d.Obtain a stat chest x-ray, then slowly wean the client's oxygen down.

ANS: B Oxygen-induced hypoventilation can occur in clients with chronically elevated PCO2 levels, such as those seen in COPD. Giving oxygen can eliminate their hypoxic drive to breathe and can cause respiratory arrest. However, hypoxemia is a greater threat to an acutely ill client than is the potential for oxygen-induced hypoventilation, and clients should be given the amount of oxygen they require. The nurse should perform a thorough respiratory assessment and should monitor the client for signs of this problem, rather than automatically reducing oxygen delivery. Blood gases and a chest x-ray will also be obtained, but they do not take priority over assessing and monitoring the client.

. A family member has been taught to provide oral care to a client with a tracheostomy. Which statement by the family member indicates an accurate understanding of the correct way to provide mouth care? a. "I can use glycerin swabs." b. "I'll use water and a toothette." c. "I can use hydrogen peroxide." d. "It is okay to use mouthwash."

ANS: B The best choice for mouth care is water and a toothette because these are the least irritating. Glycerin swabs, hydrogen peroxide, and mouthwash all are too irritating to the mucous membranes of the mouth.

A client is being discharged with a tracheostomy and voices concern about his appearance. What discharge teaching will assist the client with maintaining a positive body image? a."Tell people how sick you were when they ask about the tracheostomy." b."Your clothing can help hide the tracheostomy so it is not as noticeable." c."You can put a bandage around your tracheostomy so no one will see it." d."You have to ignore comments that people make about your appearance."

ANS: B The client may have an alteration in body image because of the tracheostomy stoma. Encourage the client to wear loose-fitting shirts and collars to help hide the appearance of the stoma. Clients should not be encouraged to tell people about their illness, because they should not be made to "justify" their appearance. You should not bandage the tracheostomy, because airflow would be impaired. Ignoring comments will not help the client's self-image.

. The nurse is preparing to receive a postoperative client who just had a tracheostomy. Which action by the nurse takes priority? a. Obtain report from the postanesthesia care unit. b. Place a second tracheostomy tube and obturator at the bedside. c. Review orders for postoperative pain medications. d. Order supplies for tracheostomy care for 24 hours.

ANS: B The nurse must ensure that a second tracheostomy tube with obturator is available at the bedside in case of accidental decannulation, because tube dislodgment in the first 72 hours is an emergency. Obtaining report and understanding pain medication orders are important for any postoperative client, but for the tracheostomy client, having the extra material on hand is critical. Obtaining supplies for tracheostomy care is not as high a priority as the other three.

A client is being weaned from a tracheostomy tube and has tolerated capping of the tube for 24 hours. Which action by the nurse is most appropriate? a. Collect all materials needed for suturing the stoma shut. b. Place a dry dressing over the stoma and tape it securely. c. Assess the client for air leaking around the tube. d. Select a smaller tracheostomy tube to be inserted.

ANS: B The tube will be able to be removed after the client has tolerated capping of it for 24 hours. Therefore, a dry dressing will be able to be placed over the stoma. The stoma will not be sutured. It will heal on its own with a small scar. Airflow should be adequate around the capped tube. The physician will not likely insert the next smallest size tube but instead will remove the existing tube.

A client is being discharged home with a tracheostomy. Which action does the nurse teach the client to decrease the risk for aspiration while eating? a. Swallow quickly. b. Thicken all liquids. c. Rinse all food with water. d. Chew food completely

ANS: B Thickening liquids may assist the client in swallowing and may help prevent aspiration. Swallowing quickly will not decrease the risk of aspiration and may actually put the client at greater risk. It is not recommended that the client drink water to wash down food. Chewing food completely will help prevent choking but will not decrease aspiration risk.

The nursing student is performing tracheostomy care on a client. Which action by the student leads the supervising nurse to intervene? a. Using folded gauze dressings on both sides of the stoma b. Cutting a slit in a gauze 4 ´ 4 pad to fit around the stoma c. Applying new tracheostomy ties before removing old ones d. Tying the twill tape in a square knot on the side of the neck

ANS: B Tracheostomy dressings should be made from gauze pads with a manufactured slit in them that fits around the tube. If none are available, use two gauze pads folded in half placed on either side of the tube. Cutting a piece of gauze could result in entry of tiny shreds of the gauze the tracheostomy. The other interventions are appropriate.

A client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the client cyanotic, with the tracheostomy tube lying on his chest. Which action by the nurse takes priority? a. Auscultate breath sounds bilaterally. b. Ventilate with a resuscitation bag and mask. c. Call a code or the Rapid Response Team. d. Insert a new obturator into the neck.

ANS: B Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. First, ventilate the client using a manual resuscitation bag and facemask while another nurse calls for help. Although auscultation of breath sounds is important, the client's airway must be opened and ventilation started. Ventilation should begin while another nurse calls the code. Reinsertion of a fresh tracheostomy tube will require the physician's intervention.

The nurse assesses a client who is receiving oxygen via a partial rebreather mask. Which assessment finding does the nurse intervene to correct? a. The bag is two thirds inflated during inhalation. b. The client's pulse oximetry reading is 93%. c. The oxygen flow rate is 2 L/min. d. The arterial oxygen level is 90%.

ANS: C Flow rate should be 6 to 11 L/min. A flow rate of 2 L/min will not adequately inflate the bag. A bag that is two thirds inflated is desired. A pulse oximetry reading of 93% and higher is adequate, as is an arterial oxygenation of 90%.

The nurse is caring for a client with a new tracheostomy. Which assessment finding requires the nurse's immediate action? a.Cuff pressure readings consistently between 14 and 20 mm Hg. b.Need to change Velcro tube holders three times in 1 day. c.Crackling sensation around the neck when skin is palpated. d.Small amount of bleeding around the incision for the first few days.

ANS: C Subcutaneous emphysema occurs when an opening or tear occurs in the trachea and air escapes into fresh tissue planes of the neck. Air can also progress through the chest and other tissues into the face. Inspect and palpate for air under the skin around the new tracheostomy. If the skin is puffy and you can feel a crackling sensation, notify the physician immediately. Cuff pressures should be maintained between 14 and 20 mm Hg or between 20 and 28 cm H2O. Tracheostomy ties need to be changed at least once a day or whenever soiled. It is not uncommon for a client with a new tracheostomy to have heavy secretions that would necessitate changing them. It is not unusual to have a small amount of bleeding around the incision for the first few days after surgical placement.

A client is to be discharged home on oxygen therapy. What information does the nurse teach the client? a. "Carry the H cylinder tank on short trips." b. "Only use the E tank when stationary." c. "The D or C cylinder can be carried." d. "Roll the tank gently when transporting."

ANS: C The D and C cylinders are small enough to be carried. The H cylinder cannot be carried. The E tank can be transported. The tanks should not be rolled and should be carried only in a stand or a rack.

Which statement by a client indicates an accurate understanding of home self-care of a tracheostomy? a. "The stoma should be left uncovered during the day to dry." b. "I need to put normal saline in my airway twice daily." c. "While showering, I need to keep water out of my airway." d. "I don't need to use tracheostomy ties on a daily basis."

ANS: C The client should put a shield over the tracheostomy to keep water from entering the airway. The airway should remain covered during the day with cotton or foam. Saline should be put in the airway 10 to 15 times daily. Tracheostomy ties should be used daily.

A client requires oxygen received via a face mask but wants to remain as mobile as possible once discharged home. Which intervention by the home health nurse best provides the client with maximal mobility? a.Arrange a consultation with pulmonary rehabilitation to decrease oxygen needs. b.Encourage the client to remove the mask occasionally to assess tolerance. c.Add extra connecting pieces of tubing to the client's existing oxygen setup. d.Change the face mask to a nasal cannula occasionally, such as at mealtimes.

ANS: C To increase mobility, up to 50 feet of connecting tubing can be used with connecting pieces. A client with a chronic respiratory condition needing home oxygen may not be able to decrease oxygen needs through pulmonary rehabilitation, but that would not increase mobility with an oxygen device. The nurse should not independently encourage the client to remove the mask for periods of time or change to a cannula

A client is becoming frustrated because of an inability to communicate with a tracheostomy. Which intervention by the nurse most effectively enhances communication? a.Explain to the client that speech will be clear and distinct with a fenestrated tube. b.Reassure the client that in time he or she will get used to the speech difficulties. c.Place a sign above the client's bed indicating that the client cannot speak. d.Provide the client with a communication board and call light within easy reach.

ANS: D A communication board and the call light will reassure the client that needs will be communicated and met. It is doubtful that the client with a tracheostomy will ever speak clearly and distinctly, no matter what type of tube he or she uses. Reassuring the client that he or she will get used to the speech difficulties does nothing to alleviate the discomfort and fear associated with impaired communication. Placing a sign above the client's bed indicating that he cannot speak will not enhance his ability to communicate, although it may help staff remember that the client has impaired communication

The nurse assesses a client during suctioning. Which finding indicates that the procedure should be stopped? a. Heart rate increases from 86 to 102 beats/min. b. Respiratory rate increases from 16 to 20 breaths/min. c. Blood pressure increases from 110/70 to 120/80 mm Hg. d. Heart rate decreases from 78 to 40 beats/min.

ANS: D A decrease in heart rate indicates that the client is not tolerating the procedure, and the vasovagal reflex may be stimulated. An increase in heart rate may be stimulated by suctioning and is expected, as is a slight increase in blood pressure. A slight increase in respiratory rate after the procedure might be caused by the feeling of oxygen being suctioned from the client's airway, along with secretions.

The nurse is caring for a client with orders for oxygen at 5 L/min. Approximately how much FiO2 is the client receiving? a. 24% b. 28% c. 36% d. 40%

ANS: D A nasal cannula can provide oxygen at 0.5 to 6 L/min, corresponding to an FiO2 range of 25% to 40%. At 5 L/min, the client is receiving 40% oxygen.

While suctioning a client who had a tracheostomy placed 4 days ago, the nurse notes particles of food in the tracheal secretions. Which action by the nurse is most appropriate? a. Increase the inflation pressure in the tracheostomy cuff. b. Add blue dye to a beverage to assess for aspiration. c. Make the client NPO and notify the health care provider. d. Perform a more thorough assessment of the client.

ANS: D Before calling the provider, the nurse needs more data, such as lung sounds, presence of cough, pulse oximetry reading, and possibly mental status. The nurse could temporarily make the client NPO while conducting this assessment, but calling the provider must wait until he or she has more complete data. The nurse should not decide to increase the inflation pressure in the tracheostomy cuff on his or her own. Adding dye to food, drink, or tube feeding formulas was commonly done in the past but should be avoided because the dye is toxic to lung tissues if aspirated.

A client has been placed on 6 L of humidified oxygen via nasal cannula. Which action by the nurse is most appropriate? a.Drain condensation back into the humidifier, maintaining a closed system. b.Keep the water sterile by draining it from the water trap back into the humidifier. c.Turn down the humidity when condensation begins to collect in the tubing. d.Remove condensation in the tubing by disconnecting and emptying it appropriately.

ANS: D Condensation often forms in the tubing when a client receives humidified high-flow oxygen. Remove this condensation as it collects by disconnecting the tubing and emptying the water. Some humidifiers and nebulizers have a water trap that hangs from the tubing so the condensation can be drained without disconnecting. To prevent bacterial contamination, never drain the fluid back into the humidifier or the nebulizer. Do not turn down the humidity because the physician has ordered it and the client needs it. Minimize how long the tubing is disconnected because the client does not receive oxygen during this period.

The nurse is teaching a family member how to suction the client's tracheostomy at home. Which information does the nurse include in the teaching plan? a. Always suction using sterile technique. b. Suction the mouth first and then the airway. c. Be prepared to recannulate the tube frequently. d. Suctioning with clean technique is acceptable.

ANS: D The family member can suction using clean technique because fewer organisms are present in the home than in the hospital. Never suction the mouth first because airway pathogenic organisms could be introduced into the airway. The family member should not be required to recannulate the tube except in an emergency