Med surg Chapter 30 Flashcards
- 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.
- 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.
- 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.
- 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.
- 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.
- A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds the client cyanotic with labored respirations. Which action does the nurse perform first?
a. Remove bedding from around the adaptor opening.
b. Listen to lung sounds and obtain a respiratory rate.
c. Call respiratory therapy to check oxygen saturation.
d. Notify the provider or Rapid Response Team immediately.
ANS: A
The Venturi mask works by drawing in a specific amount of air to mix with the oxygen through holes in an adaptor fitted at the bottom of the mask. Holes of different sizes allow different amounts of room air to be entrained, changing the amount of oxygen delivered. Bedding (or clothing) wrapped around those holes would effectively change the FiO2. The nurse should ensure that the holes remain unobstructed. Other options are appropriate but are not the first choice, because this simple step may be what solves the problem.
- A client requires oxygen received via a face mask but wants to remain as mobile as possible once discharged home. Which intervention by the home health nurse best provides the client with maximal mobility?
a. Arrange a consultation with pulmonary rehabilitation to decrease oxygen needs.
b. Encourage the client to remove the mask occasionally to assess tolerance.
c. Add extra connecting pieces of tubing to the client’s existing oxygen setup.
d. Change the face mask to a nasal cannula occasionally, such as at mealtimes.
ANS: C
To increase mobility, up to 50 feet of connecting tubing can be used with connecting pieces. A client with a chronic respiratory condition needing home oxygen may not be able to decrease oxygen needs through pulmonary rehabilitation, but that would not increase mobility with an oxygen device. The nurse should not independently encourage the client to remove the mask for periods of time or change to a cannula.
- A client has been brought in by the rescue squad to the emergency department. The client is having an acute exacerbation of chronic obstructive pulmonary disease (COPD) and is severely short of breath. On arrival, the client is on 15 L/min of oxygen via rebreather mask. Which action by the nurse takes priority?
a. Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cannula.
b. Perform a thorough respiratory assessment and attach pulse oximetry.
c. Call the laboratory to obtain arterial blood gases as soon as possible.
d. Obtain a stat chest x-ray, then slowly wean the client’s oxygen down.
ANS: B
Oxygen-induced hypoventilation can occur in clients with chronically elevated PCO2 levels, such as those seen in COPD. Giving oxygen can eliminate their hypoxic drive to breathe and can cause respiratory arrest. However, hypoxemia is a greater threat to an acutely ill client than is the potential for oxygen-induced hypoventilation, and clients should be given the amount of oxygen they require. The nurse should perform a thorough respiratory assessment and should monitor the client for signs of this problem, rather than automatically reducing oxygen delivery. Blood gases and a chest x-ray will also be obtained, but they do not take priority over assessing and monitoring the client.
- The nurse is caring for a client with orders for oxygen at 5 L/min. Approximately how much FiO2 is the client receiving?
a. 24%
b. 28%
c. 36%
d. 40%
ANS: D
A nasal cannula can provide oxygen at 0.5 to 6 L/min, corresponding to an FiO2 range of 25% to 40%. At 5 L/min, the client is receiving 40% oxygen.
- A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What does the nurse do first?
a. Notify the health care provider.
b. Assess the client’s pulse oximetry.
c. Document the observation.
d. Raise the head of the bed.
ANS: B
Cerebral hypoxia is a cause of confusion and is a sensitive indicator that the client needs more oxygen. Although you would want to notify the provider of the change in the client’s condition, the best action is first to assess pulse oximetry and then to increase the oxygen. You would not just document the assessment finding without intervening. Raising the head of the bed would not help the client oxygenate better.
- The nurse assesses a client who is receiving oxygen via a partial rebreather mask. Which assessment finding does the nurse intervene to correct?
a. The bag is two thirds inflated during inhalation.
b. The client’s pulse oximetry reading is 93%.
c. The oxygen flow rate is 2 L/min.
d. The arterial oxygen level is 90%.
ANS: C
Flow rate should be 6 to 11 L/min. A flow rate of 2 L/min will not adequately inflate the bag. A bag that is two thirds inflated is desired. A pulse oximetry reading of 93% and higher is adequate, as is an arterial oxygenation of 90%.
- A client is to be discharged home on oxygen therapy. What information does the nurse teach the client?
a. “Carry the H cylinder tank on short trips.”
b. “Only use the E tank when stationary.”
c. “The D or C cylinder can be carried.”
d. “Roll the tank gently when transporting.”
ANS: C
The D and C cylinders are small enough to be carried. The H cylinder cannot be carried. The E tank can be transported. The tanks should not be rolled and should be carried only in a stand or a rack.
- The nurse assesses a client with a new tracheotomy, and the tracheostomy tube is pulsating in synchrony with the client’s heartbeat. Which is the nurse’s priority action?
a. Notify the health care provider immediately.
b. Stabilize the tube by reapplying the ties.
c. Change the inner cannula of the tube.
d. Increase the inflation pressure of the cuff.
ANS: A
If a tracheostomy tube is pulsating with the client’s heart rate, this could indicate proximity to the innominate artery and may cause erosion of the artery if left in this position. The provider should be notified immediately. Reapplying the ties, changing the inner cannula, and increasing the inflation pressure of the cuff are all interventions that will not solve the immediate problem of proximity of the tube to the innominate artery.
- A client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the client cyanotic, with the tracheostomy tube lying on his chest. Which action by the nurse takes priority?
a. Auscultate breath sounds bilaterally.
b. Ventilate with a resuscitation bag and mask.
c. Call a code or the Rapid Response Team.
d. Insert a new obturator into the neck.
ANS: B
Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. First, ventilate the client using a manual resuscitation bag and facemask while another nurse calls for help. Although auscultation of breath sounds is important, the client’s airway must be opened and ventilation started. Ventilation should begin while another nurse calls the code. Reinsertion of a fresh tracheostomy tube will require the physician’s intervention.
- While suctioning a client who had a tracheostomy placed 4 days ago, the nurse notes particles of food in the tracheal secretions. Which action by the nurse is most appropriate?
a. Increase the inflation pressure in the tracheostomy cuff.
b. Add blue dye to a beverage to assess for aspiration.
c. Make the client NPO and notify the health care provider.
d. Perform a more thorough assessment of the client.
ANS: D
Before calling the provider, the nurse needs more data, such as lung sounds, presence of cough, pulse oximetry reading, and possibly mental status. The nurse could temporarily make the client NPO while conducting this assessment, but calling the provider must wait until he or she has more complete data. The nurse should not decide to increase the inflation pressure in the tracheostomy cuff on his or her own. Adding dye to food, drink, or tube feeding formulas was commonly done in the past but should be avoided because the dye is toxic to lung tissues if aspirated.
