Nokea
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.
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A client has a tracheostomy that is 2 days old. Upon assessment, the nurse note the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority?
- A. Assess the clients oxygen saturation.
- B. Notify the Rapid Response Team.
- C. Oxygenate the client with a bag-valve-mask.
- D. Palpate the skin of the upper chest.
Correct Answer: A
Rationale: This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the clients 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.
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.
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.
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 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.