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The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?
- A. Copious mucous secretions
- B. Sudden restlessness
- C. Harsh cough
- D. Bilateral breath sounds present
Correct Answer: B
Rationale: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube.Bilateral breath sounds are an expected finding; the absence of bilateral breath sounds should be reported to the provider immediately.
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The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
- A. Incrusted mucous membranes
- B. Hardened secretions
- C. Erosion of the trachea
- D. Noisy breathing
Correct Answer: D
Rationale: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following atracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.
The nurse is providing tracheostomy care for a client. Place the following steps in the order the nurse should perform them.
- A. Position client in a supine or low Fowler position.
- B. Using a clean glove, remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle.
- C. Open the tracheostomy kit without contaminating the contents. Don sterile gloves- keep the dominant hand sterile. Pour hydrogen peroxide and normal saline into respective containers.
- D. Unlock the inner cannula by turning it counterclockwise. Remove it and place in hydrogen peroxide. Clean the inside and outside of the cannula with pipe cleaners.
- E. Rinse the cleaned cannula with normal saline. Tap the cannula and wipe the excess solution with sterile gauze.
- F. Replace the inner cannula and turn it clockwise within the outer cannula.
- G. Clean around the stoma with an applicator moistened with normal saline.
Correct Answer: C,A,B,D,E,G,F
Rationale: The nurse should position client in a supine or low Fowler position. Using a clean glove, the nurse should remove the soiled stomal dressing and discard it, glove and all, in an appropriate receptacle. The nurse should then open the tracheostomy kit without contaminating the contents. The nurse should don sterile gloves, keeping the dominant hand sterile. Next, the nurse should pour hydrogen peroxide and normalsaline into respective containers. The nurse should then unlock the inner cannula by turning it counterclockwise, afterward removing it and placing it in hydrogen peroxide. The nurse should clean the inside and outside of the cannula with pipe cleaners. Next, the nurse should rinse the cleaned cannula with normal saline. The nurse should then tap the cannula and wipe the excess solution with sterile gauze. Next, the nurse should replace the inner cannula and turn it clockwise within the outer cannula. The nurseshould then clean around the stoma with an applicator moistened with normal saline.Next, the nurse should place a sterile dressing around the tracheostomy tube andchange the tracheostomy ties by placing the new ones on first and removing the soiled ones last. Finally, the nurse should tie the new ends securely, but not tightly, at theside of the neck. The nurse should perform hand hygiene before, during, and after the procedure.
A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy?
- A. I must carry tissues with me.
- B. I must give up my love of pool aerobics.
- C. I will not be able to have the tracheostomy removed.
- D. Tell my spouse about it, I do not want to touch it.
Correct Answer: D
Rationale: Not wanting to participate in care and diverting the care to others indicates that the client has not accepted the tracheostomy. When evaluating teaching, the nurse should assess client and caregiver ability to provide home care. It is correct to carry tissues with the client because new tracheostomy tubes produce much mucous due to the irritation of the tube in the throat. Consideration needs to be arranged but being in a swimming pool may be completed as long as water does not surround the new tracheostomy. Stating the reality of not being able to remove the tracheostomy provides data that the client is accepting the tracheostomy as part of life.
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?
- A. A ventilator
- B. A face mask
- C. A rigid shell
- D. A nasal cannula
Correct Answer: B
Rationale: A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device.
The nurse is providing suggestions to a client diagnosed with the effects of coryza. Which home remedy is appropriate when combined with medical treatment for pharyngitis?
- A. Cool mist humidifier
- B. Lavender scent
- C. Ice chips
- D. Salt water gargle
Correct Answer: D
Rationale: A salt water or saline gargle combines moisture from the water with sodium from the salt to aid in discomfort. Humidification and ice chips are also acceptable but just aids in soothing moisture to the air aiding in discomfort. A lavender scent isrelaxing but is not specifically a treatment appropriate to the condition described.