Chapter 28: Care of Patients Requiring Oxygen Therapy or Tracheostomy

Chapter 28: Care of Patients Requiring Oxygen Therapy or Tracheostomy

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. A nursing student caring for a client removes the client’s oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?
   1. 14%
   2. 21%
   3. 28%
   4. 31%

ANS:   B

Room air is 21% oxygen.

DIF:     Remembering/Knowledge                 REF: 514

KEY:   Oxygen| physiology

MSC:   Integrated Process: Nursing Process: Assessment                 NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
   1. Administer prescribed anxiolytic medication.
   2. Ensure informed consent is on the chart.
   3. Reinforce any teaching done previously.
   4. Start the preoperative antibiotic infusion.

ANS:   B

Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.

DIF:     Applying/Application                         REF: 522

KEY:   Informed consent| autonomy

MSC:   Integrated Process: Communication and Documentation  NOT:     Client Needs Category: Safe and Effective Care Environment: Management of Care

3. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client’s face is puffy and the eyelids are swollen. What action by the nurse takes priority?
   1. Assess the client’s oxygen saturation.
   2. Notify the Rapid Response Team.
   3. Oxygenate the client with a bag-valve-mask.
   4. Palpate the skin of the upper chest.

ANS:   A

This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the client’s 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.

DIF:            Applying/Application                         REF:    523                   KEY: Oxygenation| tracheostomy| nursing assessment                                                 MSC: Integrated Process: Nursing Process: Assessment                      NOT:                                                 Client Needs Category: Safe and Effective Care Environment: Management of Care

4. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?
   1. Elevate the head of the client’s bed.
   2. Measure and compare cuff pressures.
   3. Place the client on NPO status.
   4. Request that the client have a swallow study.

ANS:           B

Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This can 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.

DIF:            Analyzing/Analysis                            REF:    523                   KEY: Tracheostomy| patient safety| nursing assessment                                      MSC: Integrated Process: Nursing Process: Assessment                      NOT:                                                 Client Needs Category: Physiological Integrity: Physiological Adaptation

5. 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?
   1. Assess the client’s lung sounds.
   2. Assign a different UAP to the client.
   3. Report the UAP to the manager.
   4. Request thicker liquids for meals.

ANS:           A

The priority is to check the client’s 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 should have reported the incident immediately, but addressing that issue is not the immediate priority.

DIF:     Applying/Application             REF:    524       KEY: Delegation| aspiration| tracheostomy| nursing assessment| unlicensed assistive personnel (UAP)     MSC: Integrated Process: Nursing Process: Assessment NOT:   Client Needs Category: Physiological Integrity: Reduction of Risk Potential