Nokea
A client has a tracheostomy tube in place. The nurse is monitoring for complications associated with the tracheostomy and notes that it takes increased pressure to maintain a seal with the tracheostomy tube cuff. What action by the nurse is most appropriate?
- A. Measure tracheostomy cuff pressures.
- B. Elevate the head of the bed.
- C. Place the client on NPO status.
- D. Request that the client have a swallow study.
Correct Answer: B
Rationale: Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This may 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.
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A home health nurse is assessing the safety of a client who is on home oxygen therapy. Which statement by the client indicates a need for further teaching related to home oxygen therapy safety? (Select all that apply.)
- A. My family members smoke outside the home.
- B. All my electrical cords are in good shape.
- 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.
Correct Answer: A,B,C
Rationale: Oxygen is an accelerant, which means it enhances combustion, so precautions are needed whenever using it. The statements about family members smoking outside, electrical cords being in good shape, and flammable liquids stored in the garage indicate safe practices. Light bulbs and pets are not related to oxygen safety.
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. Cognition
- B. Dexterity
- C. Range of motion
- D. Vision
- E. Hydration
Correct Answer: A,B,D,E
Rationale: 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.
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. Create a communication system.
- B. Don't go out in public alone.
- C. Try loose-fitting shirts with collars.
- D. Wear fashionable scarves.
Correct Answer: A,C,E
Rationale: The client with a tracheostomy may be shy and hesitant to go out in public. The client should have a sound method of communication. 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.
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. Assigning a ball through patient safety/nursing assessment
Correct Answer: C
Rationale: 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 clients neck, not at the back. The other actions are appropriate.
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. Applying lip balm for the client.
- 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.
Correct Answer: A,D
Rationale: 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 should be accomplished with normal saline, not products that dry the mouth. Ensuring humidity is adequate and suctioning through the tracheostomy are nursing functions.