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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.
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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 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 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 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.