Chapter 28 Care of Patients Requiring Oxygen Therapy or Tracheostomy PDF

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TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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Chapter28:CareofPatientsRequiringOxygenTherapyor Tracheostomy MULTIPLECHOICE 1.Anursingstudentcaringforaclientremovestheclients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. DIF:Remembering/KnowledgeREF:529 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? 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. 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:537 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clientsfaceispuffyand theeyelidsareswollen.Whatactionbythenursetakespriority? a.Assesstheclients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shouldfirstassesstheclients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:538 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? a.Elevatetheheadoftheclientsbed. b.Measureandcomparecuffpressures.

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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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:538 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? a.Assesstheclientslungsounds. b.AssignadifferentUAPtotheclient. c.ReporttheUAPtothemanager. d.Requestthickerliquidsformeals. ANS:A Thepriorityistochecktheclients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:539 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 6.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 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clientsneck,notinback.Theotheractionsareappropriate. DIF:Applying/ApplicationREF:542 KEY:Tracheostomy|tracheostomycare|patientsafety|supervision MSC:IntegratedProcess:CommunicationandDocumentation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:SafetyandInfectionControl 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 ANS:A Suctionshouldonlybeappliedwhilewithdrawingthecatheter.Theotheractionsareappropriate. DIF:Remembering/KnowledgeREF:540

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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KEY:Tracheostomy|tracheostomycare|suctioning|supervision MSC:IntegratedProcess:NursingProcess:Assessment NOT: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 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 ANS:B Oxygentubingcancausepressureulcers,soclientsusingoxygenhavethenursingdiagnosisofRiskfor ImpairedSkinIntegrity.Intactskinbehindtheearsindicatesthatgoalsforthisdiagnosis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:Evaluating/SynthesisREF:530 KEY:Oxygen|skinintegrity|nursingdiagnosis|oxygentherapy MSC:IntegratedProcess:NursingProcess:Evaluation NOT: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clients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providerimmediately. ANS:D Thisclientmayhaveatracheainnominate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clien andaskssomeoneelsetonotifythe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/ApplicationREF:538 KEY:Tracheostomy|medicalemergencies|communication MSC:IntegratedProcess:NursingProcess:Implementation NOT: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nursingdiagnosisImpairedSelf-Esteemarebeingmet? a.Theclientdemonstratesgoodunderstandingofstomacare. b.Theclienthasjoinedabookclubthatmeetsatthelibrary. c.Familymemberstaketurnsassistingwithstomacare. d.Skinaroundthestomaisintactwithoutsignsofinfection. 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ImpairedSelf-Esteemarebeingmet.Theotherfindingsareallpositivesignsbutdonot relatetothisnursingdiagnosis. DIF:Evaluating/SynthesisREF:543 KEY:Tracheostomy|nursingevaluation|psychosocialresponse MSC:IntegratedProcess:NursingProcess:Evaluation NOT:ClientNeedsCategory:PsychosocialIntegrity 11.Aclientisreceivingoxygenat4literspernasalcannula.Whatcomfortmeasuremaythenursedelegateto

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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unlicensedassistivepersonnel(UAP)? a.Applywater-solubleointmenttonaresandlips. b.Periodicallyturntheoxygendownoroff. c.Removethetubingfromtheclientsnose. 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clientslipsandnares.TheUAP shouldnotadjusttheoxygenflowrateorremovethetubing.Turningtheclientisnotrelatedtocomfort measuresforoxygen. DIF:Applying/ApplicationREF:530 KEY:Oxygen|comfortmeasures|oralcare|skincare|delegation MSC:IntegratedProcess:CommunicationandDocumentation NOT: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? a.Assesstheclientsoxygensaturationand,ifnormal,turnofftheoxygen. b.Determineiftheclientcanswitchtoanasalcannuladuringthemeal. c.Havetheclientliftthemaskoffthefacewhentakingbitesoffood. d.Turntheoxygenoffwhiletheclienteatsthemealandthenrestartit. ANS:B Oxygenisadrugthatneedstobedeliveredconstantly.Thenurseshoulddetermineiftheproviderhas approvedswitchingtoanasalcannuladuringmeals.Ifnot,thenurseshouldconsultwiththeproviderabout thisissue.Theoxygenshouldnotbeturnedoff.LiftingthemasktoeatwillaltertheFiO2delivered. DIF:Applying/ApplicationREF:532 KEY:Oxygentherapy|oxygen MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:PhysiologicalIntegrity:PharmacologicalandParenteralTherapies 13.Thenurseassessestheclientusingthedevicepicturedbelowtodeliver50%O2: Thenursefinds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clients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clientsflowrateistoolowandthenurseshouldincreaseit.Afterincreasingtheflowrate,the nurseassessestheoxygensaturationanddocumentsthefindings. DIF:Analyzing/AnalysisREF:534 KEY:Oxygen|patientsafety|oxygentherapy MSC:IntegratedProcess:NursingProcess:Implementation NOT: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.) a.Theclientdoesnotallowsmokinginthehouse. b.Electricalcordsareingoodworkingorder. c.Flammableliquidsarestoredinthegarage.

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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d.Householdlightbulbsarethefluorescenttype. e.Theclientdoesnothavepetsinsidethehome. ANS:A,B,C Oxygenisanaccelerant,whichmeansitenhancescombustion,soprecautionsareneededwheneverusingit. Thenurseshouldassessiftheclientallowssmokingneartheoxygen,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. DIF:Understanding/ComprehensionREF:530 KEY:Patientsafety|fire|oxygen|homesafety|nursingassessment MSC:IntegratedProcess:NursingProcess:Assessment NOT: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 unlicensedassistivepersonnel(UAP)?(Selectallthatapply.) a.Applyingwater-solublelipbalmtotheclientslips b.Ensuringthehumidificationprovidedisadequate c.Performingoralcarewithalcohol-basedmouthwash d.Remindingtheclienttocoughanddeepbreatheoften e.Suctioningexcesssecretionsthroughthetracheostomy ANS:A,D TheUAP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thehumidityisadequateandsuctioningthroughthe tracheostomyarenursingfunctions. DIF:Applying/ApplicationREF:530 KEY:Tracheostomy|oralcare|delegation|unlicensedassistivepersonnel(UAP) MSC:IntegratedProcess:CommunicationandDocumentation NOT: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.Dont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 Theclientwithatracheostomymaybeshyandhesitanttogooutinpublic.Theclientshould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/ComprehensionREF:543 KEY:Tracheostomy|psychosocialresponse|patienteducation MSC:IntegratedProcess:Caring NOT: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

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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ANS:A,B,D,E 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shouldbeassessed.Hydrationisnotdirectlyrelatedtothe abilitytoperformself-care. DIF:Understanding/ComprehensionREF:544 KEY:Olderadult|tracheostomy|patienteducation MSC:IntegratedProcess:NursingProcess:Assessment NOT: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.Oxygen-inducedhyperventilation e.Toxicity ANS:A,B,C,E Complicationsofoxygentherapyincludeabsorptiveatelectasis,combustion,driedmucousmembranes,and oxygentoxicity.Oxygen-inducedhypoventilationisalsoacomplication. DIF:Understanding/ComprehensionREF:530 KEY:Respiratorysystem|oxygentherapy|homesafety|patienteducation MSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:SafetyandInfectionControl...