Nokea
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.
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A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
- A. Applying suction while inserting the catheter
- B. Preoxygenating the client prior to suctioning
- C. Suctioning for a total of three times
- D. Suctioning for only 10 to 15 seconds each time
Correct Answer: A
Rationale: Suction should only be applied while withdrawing the catheter. The other actions are appropriate.
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 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 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.