Nokea
Which of the following is an appropriate nursing measure when performing tracheostomy care?
- A. Wear clean gloves.
- B. Insert the catheter without suction.
- C. Suction for 1 minute before removing the catheter.
- D. Place the used catheter in a plastic shield for later use.
Correct Answer: B
Rationale: Insertion of the suction catheter without suction reduces the probability of tissue injury. Sterile gloves should be used for tracheostomy care. Suctioning should be done for a maximum of 10 seconds at a time. A used catheter should be disposed of appropriately.
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The wife of a patient with a cuffed tracheostomy asks why the cuff is inflated intermittently. What is the purpose of the inflated cuff?
- A. Prevent regurgitation after meals.
- B. Hold the trachea open until it is completely healed.
- C. Dilate the tracheal opening for passage of secretions.
- D. Prevent aspiration when eating.
Correct Answer: D
Rationale: The cuff is inflated to prevent aspiration while eating or when cleaning the tracheostomy tube.
What is the appropriate value for the Venturi mask? Oxygen delivery devices with percent of oxygen delivered
- A. 1-6 L/min = 24%-44% O2
- B. 5-8 L/min = 35%-55% O2
- C. 4-10 L/min = 24%-55% O2
- D. 6-12 L/min = 60%-90% O2
- E. 6-15 L/min = 70%-100% O2
Correct Answer: C
Rationale: Venturi mask delivers 4-10 L/min = 24%-55% O2, as per the table: Nasal cannula (1-6 L/min = 24%-44% O2), Simple face mask (5-8 L/min = 35%-55% O2), Venturi mask (4-10 L/min = 24%-55% O2), Partial rebreather mask (6-12 L/min = 60%-90% O2), Nonrebreather mask (6-15 L/min = 70%-100% O2).
When an older adult patient with chronic emphysema comes to the emergency department in respiratory distress at what rate should the nurse begin oxygen per nasal cannula?
- A. 2 L/min
- B. 3 L/min
- C. 4 L/min
- D. 5 L/min
Correct Answer: A
Rationale: Administering O2 at more than 2 L/min to a person with chronic pulmonary disease may cause respiratory failure.
An 80-year-old male patient has been admitted to the acute care facility with the diagnosis of pneumonia. He is receiving oxygen via nasal cannula at 2 L/min. The nurse assesses respirations at 24/min PaO2 level 88 mm Hg and pink skin tone. What action should the nurse implement?
- A. Notify the health care provider.
- B. Increase oxygen to 4 L/min.
- C. Record PaO2 level.
- D. Administer nebulizer treatment.
Correct Answer: C
Rationale: The nurse would document PaO2 level. Normal arterial oxygen levels sometimes decrease with age, but not usually low enough to fall outside the normal range. It may be possible for an 80-year-old person to have an arterial partial pressure oxygen (PaO2) level (the amount of oxygen found in the arterial circulation) between 80 and 85 mm Hg (normal range is 80 to 100 mm Hg) without experiencing significant alterations in health.
The nurse instructs a patient receiving home O2 therapy to drink plenty of fluids to help keep bronchial secretions liquefied. What is the recommended fluid?
- A. Milk
- B. Water
- C. Tea with artificial sweetener
- D. Coffee
Correct Answer: B
Rationale: Water is the best option. Drinks with caffeine, sugar, or dairy products are not helpful to liquefy secretions.