Nokea
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.
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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 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 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 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 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.