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Ch 28: Care of pts requiring oxygen therapy or tracheostomy Questions and Answers £11.29
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Ch 28: Care of pts requiring oxygen therapy or tracheostomy Questions and Answers
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Ch 28: Care of pts requiring oxygen therapy or tracheostomy Questions and Answers 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? a. 14% b. 21% c. 28% d. 31% ANS: B Room air is 21% oxygen....

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  • January 2, 2025
  • 5
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • ch 28 care of pts requiring oxygen therapy or tra
  • a nursing student caring for a client removes the
  • 2 a client is scheduled to have a tracheostomy pl

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Ch 28: Care of pts requiring oxygen
therapy or tracheostomy Questions and
Answers
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?
a. 14%
b. 21%
c. 28%
d. 31% - answer ANS: B
Room air is 21% oxygen.

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

. 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?
a. Assess the client's oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest. - answer NS: 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.

. 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?
a. Elevate the head of the client's bed.
b. Measure and compare cuff pressures.
c. Place the client on NPO status.
d. Request that the client have a swallow study. - answer 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.

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?
a. Assess the client's lung sounds.
b. Assign a different UAP to the client.
c. Report the UAP to the manager.
d. Request thicker liquids for meals. - answer 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.

. 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. Using half-strength peroxide for cleansing - answer ANS: C
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 client's neck, not in back. The other
actions are appropriate.

7. 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 if needed
d. Suctioning for only 10 to 15 seconds each time - answer ANS: A
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
A - answer NS: B

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