Deck 30: Care of Patients Requiring Oxygen Therapy or Tracheostomy

Question 1

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.

Answer 1

Provide the client with a communication board and call light within easy reach.

Question 2

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."

Answer 2

"I'm glad I will still be able to talk with this tube in place."

Question 3

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%

Answer 3

40%

Question 4

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.

Question 5

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.

Question 6

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.

Question 7

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

Question 8

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.

Question 9

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.

Question 10

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.

Question 11

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.

Question 12

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."

Question 13

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."

Question 14

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.

Question 15

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.

Question 16

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

Question 17

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.

Question 18

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

Question 19

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.

Question 20

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%.

Question 21

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."

Question 22

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.

Question 23

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.

Question 24

Which interventions help to prevent aspiration during eating for a client with a tracheostomy?

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.

Question 25

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.

Question 26

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.

Question 27

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."