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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.
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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 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 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 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.
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.