Nokea
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.
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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. $100\%$ of meals being eaten by the client
- B. Intact skin behind the ears
- C. The client understanding the need for oxygen
- D. Unchanged weight for the past 3 days
Correct Answer: B
Rationale: 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. Understanding the need for oxygen is important but would not take priority over a physical problem.
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. Assess the clients lung sounds.
- B. Assign a different UAP to the client.
- C. Report the UAP to the manager.
- D. Request thicker liquids for meals.
Correct Answer: A
Rationale: The priority is to check the clients 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 does not necessarily need to be reported, and addressing that issue is not the immediate priority.
A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the clients pulse is taken. No other abnormal findings are noted. What action by the nurse is most appropriate?
- A. Indicate to the provider a pending emergency case.
- B. No action is needed at this time; this is a normal finding in some clients.
- C. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
- D. Stay with the client and have someone else call the provider immediately.
Correct Answer: D
Rationale: The client may have a tracheo-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 to the bleeding site.
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 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.