Question 1

A client is receiving oxygen at 4 liters per nasal cannula.What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?

Accepted Answer

Oxygen can be drying,so the UAP can apply water-soluble lubricant to the client's lips and nares.The UAP should not adjust the oxygen flow rate or remove the tubing.Turning the client is not related to comfort measures for oxygen.

Question 2

A client is scheduled to have a tracheostomy placed in an hour.What action by the nurse is the priority?

Accepted Answer

Since this is an operative procedure,the client must sign an informed consent,which must be on the chart.Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.

Question 3

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 3 L/min.What action by the nurse is best?

Accepted Answer

For the Venturi mask to deliver high flow of oxygen,the flow rate must be set correctly,usually between 4 and 10 L/min.The client's flow rate is too low and the nurse should increase it.After increasing the flow rate,the nurse assesses the oxygen saturation and documents the findings.

Question 4

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? (Select all that apply.)

Accepted Answer

Oxygen is an accelerant,which means it enhances combustion,so precautions are needed whenever using it.The nurse should assess if the client allows smoking near the oxygen,whether electrical cords are in good shape or are frayed,and if flammable liquids are stored (and used)in the garage away from the oxygen.Light bulbs and pets are not related to oxygen safety.

Question 5

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived.What action by the nurse is best?

Accepted Answer

Oxygen is a drug that needs to be delivered constantly.The nurse should determine if the provider has approved switching to a nasal cannula during meals.If not,the nurse should consult with the provider about this issue.The oxygen should not be turned off.Lifting the mask to eat will alter the FiO₂ delivered.

Question 6

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?

Accepted Answer

Oxygen tubing can cause pressure ulcers,so clients using oxygen have the nursing diagnosis of Risk for Impaired Skin Integrity.Intact skin behind the ears indicates that goals for this diagnosis are being met.Nutrition and weight are not related to using oxygen.Understanding the need for oxygen is important but would not take priority over a physical problem.

Question 7

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?

Accepted Answer

Room air is 21% oxygen.

Question 8

A client with a new tracheostomy is being seen in the oncology clinic.What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?

Accepted Answer

The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for Impaired Self-Esteem are being met.The other findings are all positive signs but do not relate to this nursing diagnosis.

Question 9

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?

Accepted Answer

Constant pressure from the tracheostomy tube cuff can cause tracheomalacia,leading to dilation of the tracheal passage.This can be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated.The nurse should measure the pressures and compare them to previous ones to detect a trend.Elevating the head of the bed,placing the client on NPO status,and requesting a swallow study will not correct this situation.

Question 10

A nurse is caring for a client who has a tracheostomy tube.What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.)

Accepted Answer

The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises.Oral care can be accomplished with normal saline,not products that dry the mouth.Ensuring the humidity is adequate and suctioning through the tracheostomy are nursing functions.

Question 11

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 noted.What action by the nurse is most appropriate?

Accepted Answer

This client may have a trachea-innominate artery fistula,which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage.Since no bleeding is yet present,the nurse stays with the client and asks someone else to notify the provider.If the client begins hemorrhaging,the nurse removes the tracheostomy and applies pressure at the bleeding site.The client will need to be prepared for surgery.

Question 12

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? (Select all that apply.)

Accepted Answer

The older adult is at risk for having impairments in cognition,dexterity,range of motion,and vision that could limit the ability to perform tracheostomy care and should be assessed.Hydration is not directly related to the ability to perform self-care.

Question 13

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?

Accepted Answer

This client may have subcutaneous emphysema,which is air that leaks into the tissues surrounding the tracheostomy.The nurse should first assess the client's oxygen saturation and other indicators of oxygenation.If the client is stable,the nurse can palpate the skin of the upper chest to feel for the air.If the client is unstable,the nurse calls the Rapid Response Team.Using a bag-valve-mask device may or may not be appropriate for the unstable client.

Question 14

A student nurse is providing tracheostomy care.What action by the student requires intervention by the instructor?

Accepted Answer

To prevent pressure ulcers and for client safety,when ties are used that must be knotted,the knot should be placed at the side of the client's neck,not in back.The other actions are appropriate.

Question 15

A client is being discharged home after having a tracheostomy placed.What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.)

Accepted Answer

The client with a tracheostomy may be shy and hesitant to go out in public.The client should have a sound communication method to ease frustration.The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house.These can include wearing scarves and loose-fitting shirts to hide the stoma.Keeping the client homebound is not good advice.

Question 16

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? (Select all that apply.)

Accepted Answer

Complications of oxygen therapy include absorptive atelectasis,combustion,dried mucous membranes,and oxygen toxicity.Oxygen-induced hypoventilation is also a complication.

Question 17

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?

Accepted Answer

The priority is to check the client's oxygenation because he or she may have aspirated.Once the client has been assessed,the nurse can consult with the registered dietitian about appropriately thickened liquids.The UAP should have reported the incident immediately,but addressing that issue is not the immediate priority.

Question 18

A student is practicing suctioning a tracheostomy in the skills laboratory.What action by the student demonstrates that more teaching is needed?

Accepted Answer

Suction should only be applied while withdrawing the catheter.The other actions are appropriate.

Quiz 28: Care of Patients Requiring Oxygen Therapy or Tracheostomy

A client is receiving oxygen at 4 liters per nasal cannula.What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) ?

A client is scheduled to have a tracheostomy placed in an hour.What action by the nurse is the priority?

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 3 L/min.What action by the nurse is best?

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? (Select all that apply.)

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived.What action by the nurse is best?

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 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 client with a new tracheostomy is being seen in the oncology clinic.What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?

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 nurse is caring for a client who has a tracheostomy tube.What actions may the nurse delegate to unlicensed assistive personnel (UAP) ? (Select all that apply.)

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 noted.What action by the nurse is most appropriate?

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? (Select all that apply.)

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 student nurse is providing tracheostomy care.What action by the student requires intervention by the instructor?

A client is being discharged home after having a tracheostomy placed.What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.)

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? (Select all that apply.)

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 student is practicing suctioning a tracheostomy in the skills laboratory.What action by the student demonstrates that more teaching is needed?

Quiz 28: Care of Patients Requiring Oxygen Therapy or Tracheostomy

A client is receiving oxygen at 4 liters per nasal cannula.What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP) ?

A client is scheduled to have a tracheostomy placed in an hour.What action by the nurse is the priority?

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 3 L/min.What action by the nurse is best?

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? (Select all that apply.)

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived.What action by the nurse is best?

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 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 client with a new tracheostomy is being seen in the oncology clinic.What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?

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 nurse is caring for a client who has a tracheostomy tube.What actions may the nurse delegate to unlicensed assistive personnel (UAP) ? (Select all that apply.)

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 noted.What action by the nurse is most appropriate?

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? (Select all that apply.)

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 student nurse is providing tracheostomy care.What action by the student requires intervention by the instructor?

A client is being discharged home after having a tracheostomy placed.What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.)

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? (Select all that apply.)

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 student is practicing suctioning a tracheostomy in the skills laboratory.What action by the student demonstrates that more teaching is needed?

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 3 L/min.What action by the nurse is best?