Nokea
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.
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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 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.
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 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 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.