NUR2243 Module 2 EAQs
In a patient 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 patient?
Dilation
To prevent aspiration during swallowing in a patient with a tracheostomy, what does the nurse suggest?
Thicken all liquids to increase consistency.
A patient who smokes is being discharged home on oxygen. The patient states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response?
"You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."
A patient who is concerned about getting a tracheostomy says, "I will be ugly with a hole in my neck." What is the nurse's best response?
"Do you have a scarf or a large loose collar that you could place over it?"
The nurse is teaching a patient with a tracheostomy who is to be discharged about home tracheostomy management. Which statement by the patient indicates that further instruction may be needed?
"I should sleep in a room with a dehumidifier."
A registered nurse is educating nursing students about precautions to prevent aspiration during swallowing in patients with tracheostomy tubes in place. Which nursing student statements require further teaching? Select all that apply.
"I'll give water and other 'thin' liquids to the patient." "I'll position the patient in the most relaxed position possible." "I'll assist the patient in turning in bed at regular intervals."
The nurse is preparing a patient who has chronic hypoxia to return home with an oxygen concentrator. Which statement made by the patient about the concentrator indicates teaching has been effective?
"It does not require refilling with liquid oxygen."
The nurse is educating a patient and the caregivers at the time of discharge about home care after a tracheostomy. Which teachings would be beneficial for the patient? Select all that apply.
"Perform airway care." "Wear a shower shield." "Wear a medical alert bracelet."
Which of these instructions reflects best practices for suctioning the artificial airway? Select all that apply.
"Wash hands." "Don protective eyewear." "Maintain standard precautions."
Which cuff pressure should be maintained in a tracheostomy or endotracheal tube to prevent mucosal ischemia?
14-20 mm Hg
The nurse assesses a patient with pneumonia who has been receiving oxygen 45% via Venturi mask for 2 days and notes dyspnea when getting to a chair and a nonproductive cough. The patient reports chest pain below the sternum and gastrointestinal (GI) upset. Which initial action by the nurse is correct?
Contact the provider to report these findings.
When caring for the patient with hypercarbia who is receiving supplemental oxygen, why must the nurse use caution with the rate of administration?
A lower arterial oxygen level provides the stimulus to breathe.
The spouse of a patient 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?
Addressing approaches for the patient to communicate with the tracheostomy
Which action does the nurse take if a patient develops bradycardia during nasopharyngeal suctioning?
Administer 100% oxygen by bag-valve-mask.
A patient who has thick, sticky respiratory secretions requires high-flow, humidified oxygen delivery. Which oxygen delivery equipment does the nurse use for this patient?
Aerosol mask
Which laboratory tests provide valuable information to the nurse when caring for a patient requiring oxygen therapy? Select all that apply.
Arterial blood gases Hemoglobin and hematocrit
During shift report, the nurse learns the assigned patient with chronic lung disease is receiving oxygen at 4 L/min per nasal cannula. When entering the patient's room, what is the nurse's initial action?
Assess oxygen saturation with a pulse oximeter.
Vagal stimulation during suctioning can contribute to which conditions? Select all that apply.
Asystole Heart block Bradycardia
The nurse assesses a patient who is receiving oxygen using a partial rebreather facemask at a flow rate of 12 L/min. The nurse notes the patient's oxygen saturation level is 90%. Which action would the nurse take next?
Change the mask to a non-rebreather mask.
Which assessment findings may indicate a tracheostomy tube is obstructed? Select all that apply.
Dyspnea Noisy respirations Difficulty inserting a suction catheter
The nurse is assisting a patient with a tracheostomy to eat. Which is an important nursing action to help the patient swallow and avoid aspiration?
Elevate the head of the bed for at least 30 minutes after eating.
When administering oxygen to a patient at 5 L/min per nasal cannula, which intervention does the nurse include in the patient's plan of care?
Ensure that oxygen bubbles through the water in the humidifier.
A patient has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially?
Face tent
The nurse is caring for a patient with facial burns from a house fire. Which mode of oxygen delivery is recommended for this patient?
Face tent
A prescription for oxygen therapy for a patient who has been on a Venturi mask indicates a need for 80% Fio 2. What do the options to fulfill this order include? Select all that apply.
Face tent Aerosol mask
In caring for a patient during the first few days after tracheostomy placement, what nursing action is included in wound care?
Folding standard gauze 4 × 4s to fit around the tube
When suctioning a tracheostomy or endotracheal tube, what nursing actions ensure safe and effective practice? Select all that apply.
If needed, repeating suctioning up to three passes When suctioning, using a gentle twirling motion of the catheter Preoxygenating the patient with 100% oxygen for 30 seconds to 3 minutes before suctioning
Which factors should be taken into consideration when determining the type of oxygen delivery system to be used for a patient? Select all that apply.
Importance of humidity Oxygen concentration required by the patient Oxygen concentration achieved by a delivery system
Which factor is a manifestation of tracheoesophageal fistula (TEF)?
Increased cough and choking while eating
Which factors should be considered when determining which type of oxygen a patient will require for home oxygen therapy? Select all that apply.
Liquid oxygen is available in lightweight, easy-to-carry containers. Liquid oxygen tanks last longer than equal-sized gaseous oxygen tanks.
Which technique or action does the nurse use to prevent a tracheoesophageal fistula (TEF) in a patient after a tracheotomy has been performed?
Maintain proper cuff pressure.
Which of these oxygen delivery systems is known to deliver low-flow fraction of inspired oxygen (FiO 2)?
Nasal cannula
Which principles are important for the nurse to remember about oxygen administration? Select all that apply.
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.
A patient receiving oxygen via nasal cannula at a rate of 4 L/min reports irritation of the nose, and the nurse notes dry, reddened nostrils. Which action by the nurse is correct?
Notify respiratory therapy for humidification per provider order.
The nurse assesses a patient who has begun receiving oxygen therapy of 40% via Venturi mask and notes pink lips and nail beds and a pulse oximetry value of 98%. The patient is sleeping and has a heart rate of 76 beats per minute, a respiratory rate of 6 breaths per minute, and breaths are nonlabored and shallow. What is the nurse's correct initial response?
Notify the provider of the patient's respiratory rate and breathing pattern.
Which principle should guide the nurse's decision regarding oral care for a patient with a tracheostomy during the first 24 hours postoperative?
Oral care is indicated to decrease the accumulation of organisms.
When providing suctioning through an endotracheal or tracheostomy tube, what alerts the nurse to stop suctioning?
Oxygen saturation by pulse oximetry is less than 90%.
When assessing the adequacy of a patient's oxygenation, which information is important for the nurse to note?
Partial pressure of arterial oxygen (PaO 2)
The older adult patient with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this patient during the postoperative period?
Picture board
The risk for aspiration with a tracheostomy tube in place is related to which factor?
Proximity of the tracheostomy tube to the epiglottis
The nurse is suctioning a patient's tracheostomy and notes a heart rate of 98 and an oxygen saturation of 89% during the procedure. Which action by the nurse is correct?
Reoxygenate the patient with a 100% oxygen delivery system.
Which instance would make the treatment with continuous positive airway pressure (CPAP) ineffective?
Respiratory failure following extubation
Low-flow oxygen delivery systems typically include which types of components? Select all that apply.
Simple facemask Nonrebreather mask
An older adult patient is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN?
Suction the tracheostomy using sterile technique.
A patient with sleep apnea has a new prescription for a BiPAP device to be worn at night. What does the nurse include in the teaching for this assistive device? Select all that apply.
The mask must fit tightly to form a proper seal. BiPAP provides positive pressure during inhalation and exhalation to keep alveoli open. BiPAP improves airflow during sleep and promotes comfort by reducing dyspnea.
When the inner cannula is removed from a fenestrated tracheostomy tube, what is an expected patient function?
The patient will be able to speak.
When providing care to a patient with a recently placed tracheostomy who is on a mechanical ventilator, which principle guides nursing care?
The pilot balloon should be inflated.
The health care provider has suggested placing a patient with chronic obstructive pulmonary disease (COPD) on noninvasive positive-pressure ventilation (NPPV) to improve gas exchange. What information is important to discuss with the patient before starting NPPV? Select all that apply.
Tight-fitting masks can lead to skin breakdown. Mask leaks can cause pressure around the eyes. NPPV may require nasal gastric tube placement. There is a risk of aspiration due to gastric inflation.
What is one of the purposes of oxygen therapy?
To have an acceptable blood oxygen level
Immediately after having a tracheostomy tube removed as ordered by the provider, the patient begins to cough and has difficulty breathing, talking, and clearing secretions. After notifying the provider, the nurse anticipates an order for which procedure?
Tracheal dilation
Which condition causes subcutaneous emphysema in a patient with a new tracheostomy?
Trapping of air escaped into the tissues
What are typical postoperative concerns after a new tracheostomy? Select all that apply.
Tube obstruction Tube dislodgement Accidental decannulation
The nurse is suctioning a patient who has a tracheostomy and notes a pulse oximetry reading of 90% during the procedure. Which action does the nurse take?
Use a manual resuscitation bag to deliver 100% oxygen before resuming.
What does the nurse include in the discharge teaching of a patient with a laryngectomy and tracheostomy?
Use colored seam binding as tracheostomy ties after the stoma has matured.
A patient is receiving oxygen therapy. What are potential sources of infection the nurse should address? Select all that apply.
Use of a heated humidifier or nebulizer Use of an oral suction catheter in the endotracheal tube
The patient coughs and expels the tracheostomy tube. The nurse inserts a new tracheostomy tube and auscultates the lungs but cannot hear breath sounds. What is the nurse's next best action?
Ventilate with a bag-valve-mask and ensure the Rapid Response Team is notified.
What is the greatest priority while providing care to a patient with a tracheostomy?
When changing the ties, having someone assist by holding the tube until it is securely stable
Which instructions should be included in the teaching regarding proper tracheostomy care? Select all that apply.
"Set up a sterile field." "Assemble the necessary equipment." "Suction the tracheostomy tube, if necessary."
A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen with a Venturi mask at a rate of 3 L/min. Prior to initiating oxygen therapy, the patient appeared anxious with gray skin, a respiratory rate of 24 breaths/min, and an oxygen saturation of 87%. After 15 minutes of oxygen therapy, the nurse observes the patient resting with closed eyes, pink coloration, a respiratory rate of 12 breaths/min, and an oxygen saturation of 95%. Which action by the nurse is correct?
Decrease the oxygen to 2 L/min to improve respiratory rate.
Which symptom indicates tube obstruction in a patient with tracheostomy?
Difficulty in breathing
