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
21%
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
Ensure informed consent is on the chart.
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?
Assess the clients oxygen saturation.
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?
Measure and compare cuff pressures.
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?
Assess the clients lung sounds.
A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor?
Tying a square knot at the back of the neck
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
Applying suction while inserting the catheter
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?
Intact skin behind the ears
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?
Stay with the client and have someone else call the provider immediately.
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?
The client has joined a book club that meets at the library.
A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?
Apply water-soluble ointment to nares and lips.
A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best?
Determine if the client can switch to a nasal cannula during the meal.
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?
Immediately increase the flow rate.
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.)
The client does not allow smoking in the house.
Electrical cords are in good working order.
Flammable liquids are stored in the garage.
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.)
Applying water-soluble lip balm to the clients lips
Reminding the client to cough and deep breathe often
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.)
Create a communication system.
Try loose-fitting shirts with collars.
Wear fashionable scarves.
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.)
Cognition
Dexterity
Range of motion
Vision
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.)
Absorptive atelectasis
Combustion
Dried mucous membranes
Toxicity