Nokea
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.
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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 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 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.
A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?
- A. Apply water-soluble ointment to nares and lips.
- B. Periodically turn the oxygen down or off.
- C. Remove the tubing from the clients nose.
- D. Turn the client every 2 hours or as needed.
Correct Answer: A
Rationale: Oxygen can be drying, so the UAP can apply water-soluble lubricant to the clients lips and nares. The UAP should not adjust the oxygen flow rate or remove the tubing. Turning the client is not related to comfort measures for oxygen.
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.