Medsurg Chapter 28
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the client's oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.
a
A client is being discharged home after having a tracheostomy placed. What suggestion does the nurse offer to help the client maintain self-esteem? 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
A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to UAP? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Remove the tubing from the client's nose. d. Turn the client every 2 hours or as needed.
a
A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? a. The client 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 client does not have pets inside the home.
a
A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to UAP? a. Applying water-soluble lip balm to the client's lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy
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 client 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 client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority? a. Assess the client's lung sounds. b. Assign a different UAP to the client. c. Report the UAP to the manager. d. Request thicker liquids for meals.
a
A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision
a, b, d, e
A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Oxygen-induced hyperventilation e. Toxicity
a,b,c,e
A nursing student caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31%
b
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the client's bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.
b
A client 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 informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.
b
A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best?a. Assess the client's oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it
b
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates the goals for the nursing diagnosis Impaired Self-Esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client 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 nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met? a. 100% of meals being eaten by the client b. Intact skin behind the ears c. The client understanding the need for oxygen d. Unchanged weight for the past 3 days
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 client 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 client using the device pictured below to deliver 50% O2: The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3L/min. What action by the nurse is best?a. Assess the client'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 client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are being 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 clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the provider immediately.
d