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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.
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A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?
- A. 24%
- B. 21%
- C. 33%
- D. 31%
Correct Answer: B
Rationale: Room air is 21% oxygen.
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.
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. 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.
Correct Answer: B
Rationale: 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.
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.)
- A. Absorptive atelectasis
- B. Combustion
- C. Dried mucous membranes
- D. Oxygen-induced hyperventilation
- E. Toxicity
Correct Answer: A,B,C,D,E
Rationale: Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, oxygen-induced hyperventilation, and oxygen toxicity.
A client is scheduled to have a tracheostomy
- A. Administer prescribed anxiolytic medication
- B. Ensure informed consent is on the chart
- C. Reinforce any teaching done previously
- D. Start new teaching for the procedure
Correct Answer: B
Rationale: Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytic and antibiotics and reinforcing teaching may also be required but do not take priority.