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Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

Chapter 25: Concepts of Care for Patients Requiring Oxygen Therapy or Tracheostomy Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse 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

Oxygen content of atmospheric or “room air” is about 21%. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Oxygen, Physiology MSC: 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? a. Administer prescribed anxiolytic medication. b. Ensure that informed consent is on the chart. c. Reinforce any teaching done previously. d. 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 TOP: Integrated Process: Communication and Documentation KEY: Informed consent, Autonomy MSC: 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 that the

client’s face is puffy and the eyelids are swollen. What action by the nurse takes best? 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. ANS: A

This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse would 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

TOP: Integrated Process: Nursing Process: Assessment

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) KEY: Oxygenation, Tracheostomy, Nursing assessment MSC: 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? 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. 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 would 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: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Tracheostomy, Client safety MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. An assistive personnel (AP) 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 is best? a. Assess the client’s lung sounds. b. Assign a different AP to the client. c. Report the AP to the manager. d. Request thicker liquids for meals. ANS: A

The best action is to check the client’s oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse would notify the primary health care provider of possible aspiration and would 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 TOP: Integrated Process: Nursing Process: Assessment KEY: Aspiration, Tracheostomy MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 6. A nurse is providing tracheostomy care. What action by the nurse requires intervention by

the charge nurse? 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 ANS: C

To prevent pressure injuries and for client safety, when ties are used that must be knotted, the knot would be placed at the side of the client’s neck, not in back. The other actions are appropriate.

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Tracheostomy care, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 7. A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What

action by the student demonstrates that more teaching is needed? Applying suction while inserting the catheter Preoxygenating the client prior to suctioning Suctioning for a total of three times if needed Suctioning for only 10 to 15 seconds each time

a. b. c. d.

ANS: A

Suction would only be applied while withdrawing the catheter. The other actions are appropriate. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Tracheostomy, Suctioning MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 8. A nurse is caring for a client using oxygen while in the hospital. What assessment finding

indicates that outcomes for client safety with oxygen therapy 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 ANS: B

Oxygen tubing can cause pressure injuries, so clients using oxygen have a high risk of skin breakdown. Intact skin behind the ears indicates that goals for maintaining client safety with oxygen therapy are being met. Nutrition and weight are not related to using oxygen. Understanding the need for oxygen is important but would not take priority over a physical problem. DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Oxygen therapy, Skin integrity MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 9. A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy

tube is pulsing with the heartbeat as the client’s pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the primary health care provider immediately. ANS: D

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

This client may have a tracheoinnominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the primary health care provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Tracheostomy, Medical emergencies MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. A client with a new tracheostomy is being seen in the oncology clinic. What finding by the

nurse best indicates that goals for the client’s decrease in self-esteem are being met? The client demonstrates good understanding of stoma care. The client has joined a book club that meets at the library. Family members take turns assisting with stoma care. Skin around the stoma is intact without signs of infection.

a. b. c. d.

ANS: B

The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for disrupted self-esteem are being met. The other findings are all positive signs but do not relate to this client problem. DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Tracheostomy, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 11. A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse

delegate to assistive personnel (AP)? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Replaces the oxygen tubing with a different type. d. Turn the client every 2 hours or as needed. ANS: A

Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client’s lips and nares. The AP would not adjust the oxygen flow rate or replace the tubing. Turning the client is not related to comfort measures for oxygen. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Oxygen, Comfort measures, Delegation MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort 12. A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What

action by the nurse is best? Assess the client’s oxygen saturation and, if normal, turn off the oxygen. Determine if the client can switch to a nasal cannula during the meal. Have the client lift the mask off the face when taking bites of food. Turn the oxygen off while the client eats the meal and then restart it.

a. b. c. d.

ANS: B

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

Oxygen is a drug that needs to be delivered constantly. The nurse would determine if the primary health care provider has approved switching to a nasal cannula during meals. If not, the nurse would consult with the primary health care provider about this issue. The primary health care provider would need to prescribe discontinuing oxygen if the client’s oxygen saturation is normal. The oxygen would not be turned off. Lifting the mask to eat will alter the FiO2 delivered. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Oxygen therapy, Oxygen MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 13. The nurse assesses the client using the device pictured below to deliver 50% O 2:

The nurse finds that the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? a. Assess the client’s oxygen saturation. b. Document these findings in the chart. c. Immediately increase the flow rate. d. Turn the flow rate down to 2 L/min. ANS: C

For the venturi mask to deliver high flow of oxygen, the flow rate must be set correctly, usually between 4 and 10 L/min. The client’s flow rate is too low and the nurse would increase it. After increasing the flow rate, the nurse assesses the oxygen saturation and documents the findings. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Oxygen therapy, Client safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. A home health nurse is visiting a new client who uses oxygen in the home. For which factors

does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.)

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) a. b. c. d. e. f.

The client does not allow smoking in the house. Electrical cords are in good working order. Flammable liquids are stored in the garage. Household light bulbs are the fluorescent type. The client does not have pets inside the home. No alcohol-based hand sanitizers are present.

ANS: A, B, C

Oxygen it enhances combustion, so precautions are needed whenever using it. The nurse would assess if the client allows smoking in the house, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety. Alcohol-based hand sanitizers are permitted. DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Oxygen therapy, Home safety MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse

delegate to assistive personnel (AP)? (Select all that apply.) Applying water-soluble lip balm to the client’s lips Ensuring that the humidification provided is adequate Performing oral care with alcohol-based mouthwash Reminding the client to cough and deep breathe often Suctioning excess secretions through the tracheostomy Holding the new tracheostomy tube while the RN changes the ties

a. b. c. d. e. f.

ANS: A, D

The AP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring that the humidity is adequate and suctioning through the tracheostomy are nursing functions. When needed, a second licensed person assists with holding the tracheostomy tube during tie changes; some hospitals require a second licensed person during the first 72 hours after placement. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Tracheostomy, Delegation MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. 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. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves. ANS: A, D, E

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

The client with a tracheostomy may be shy and hesitant to go out in public. The client needs to have a sound communication method to ease frustration. 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. DIF: Understanding TOP: Integrated Process: Caring KEY: Tracheostomy, Psychosocial response, Client education MSC: Client Needs Category: Psychosocial Integrity 4. A nurse is planning discharge teaching on tracheostomy care for an older client. What factors

does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision f. Upper arm range of motion ANS: A, B, D, E, F

The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could limit the ability to perform tracheostomy care and would be assessed. Upper arm mobility is required to perform tracheostomy self-care. Hydration is not directly related to the ability to perform self-care. DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Tracheostomy, Older adult MSC: Client Needs Category: Health Promotion and Maintenance 5. 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. Alveolar recruitment e. Toxicity ANS: A, B, C, E

Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and oxygen toxicity. Alveolar recruitment may be a benefit of high-flow nasal cannulas such as Vapotherm, which both humidifies and warms the oxygen. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Oxygen therapy, Health teaching MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control...