ATI Care of Patients Requiring Oxygen Therapy or Tracheostomy, Questions and Answers with Explanations

1. The nurse is caring for a client with a new tracheostomy. Which assessment finding requires the nurse’s immediate action?

a.	Cuff pressure readings consistently between 14 and 20 mm Hg.
b.	Need to change Velcro tube holders three times in 1 day.
c.	Crackling sensation around the neck when skin is palpated.
d.	Small amount of bleeding around the incision for the first few days.

ANS: C

Subcutaneous emphysema occurs when an opening or tear occurs in the trachea and air escapes into fresh tissue planes of the neck. Air can also progress through the chest and other tissues into the face. Inspect and palpate for air under the skin around the new tracheostomy. If the skin is puffy and you can feel a crackling sensation, notify the physician immediately. Cuff pressures should be maintained between 14 and 20 mm Hg or between 20 and 28 cm H₂O. Tracheostomy ties need to be changed at least once a day or whenever soiled. It is not uncommon for a client with a new tracheostomy to have heavy secretions that would necessitate changing them. It is not unusual to have a small amount of bleeding around the incision for the first few days after surgical placement.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

2. A client has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar. Which assessment finding requires immediate action by the nurse?

a.	Constant, nonproductive coughing
b.	Blood-tinged sputum
c.	Rhonchi in upper lobes
d.	Dry mucous membranes

ANS: A

Causes and manifestations of lung injury from oxygen toxicity include nonproductive cough, substernal chest pain, GI upset, and dyspnea. Blood-tinged sputum is expected in clients with new tracheostomies. Rhonchi in upper lobes indicates sputum that can be expectorated and is not an emergent problem. Dry mucous membranes should be lubricated, and the client’s hydration status can be checked.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

3. A client has been placed on 6 L of humidified oxygen via nasal cannula. Which action by the nurse is most appropriate?

a.	Drain condensation back into the humidifier, maintaining a closed system.
b.	Keep the water sterile by draining it from the water trap back into the humidifier.
c.	Turn down the humidity when condensation begins to collect in the tubing.
d.	Remove condensation in the tubing by disconnecting and emptying it appropriately.

ANS: D

Condensation often forms in the tubing when a client receives humidified high-flow oxygen. Remove this condensation as it collects by disconnecting the tubing and emptying the water. Some humidifiers and nebulizers have a water trap that hangs from the tubing so the condensation can be drained without disconnecting. To prevent bacterial contamination, never drain the fluid back into the humidifier or the nebulizer. Do not turn down the humidity because the physician has ordered it and the client needs it. Minimize how long the tubing is disconnected because the client does not receive oxygen during this period.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)

4. A client is being discharged with a tracheostomy and voices concern about his appearance. What discharge teaching will assist the client with maintaining a positive body image?

a.	“Tell people how sick you were when they ask about the tracheostomy.”
b.	“Your clothing can help hide the tracheostomy so it is not as noticeable.”
c.	“You can put a bandage around your tracheostomy so no one will see it.”
d.	“You have to ignore comments that people make about your appearance.”

ANS: B

The client may have an alteration in body image because of the tracheostomy stoma. Encourage the client to wear loose-fitting shirts and collars to help hide the appearance of the stoma. Clients should not be encouraged to tell people about their illness, because they should not be made to “justify” their appearance. You should not bandage the tracheostomy, because airflow would be impaired. Ignoring comments will not help the client’s self-image.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)

MSC: Integrated Process: Caring

5. A client is becoming frustrated because of an inability to communicate with a tracheostomy. Which intervention by the nurse most effectively enhances communication?

a.	Explain to the client that speech will be clear and distinct with a fenestrated tube.
b.	Reassure the client that in time he or she will get used to the speech difficulties.
c.	Place a sign above the client’s bed indicating that the client cannot speak.
d.	Provide the client with a communication board and call light within easy reach.

ANS: D

A communication board and the call light will reassure the client that needs will be communicated and met. It is doubtful that the client with a tracheostomy will ever speak clearly and distinctly, no matter what type of tube he or she uses. Reassuring the client that he or she will get used to the speech difficulties does nothing to alleviate the discomfort and fear associated with impaired communication. Placing a sign above the client’s bed indicating that he cannot speak will not enhance his ability to communicate, although it may help staff remember that the client has impaired communication.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)

MSC: Integrated Process: Caring

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