A nurse 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 that informed consent is on the chart
A client has a tracheostomy that is 3 days old upon assessment the nurse notes that the clients face is puffy and the eyelids are swollen what action by the nurse takes best
Assess the clients oxygen saturation
A client has a tracheostomy tube in place when the nurse suctions food particles are noted what action by the nurse is best
Measure and compare cuff pressures
An assistive personnel (AP) was feeding a client with a tracheostomy later that evening the UAP reports that the client has a coughing spell during the meal what action by the nurse is best
Assess the clients lung sounds
A nurse is providing tracheostomy care what action by the nurse requires intervention by the charge nurse
Tying a square knot at the back of the neck
A nurse demonstrating suctioning a tracheostomy during the annual skills review what action by the student demonstrates the 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 outcomes for client safety with oxygen therapy 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 primary health care 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 clients decrease in self esteem are being met
The client has joined a book club that meets in the library
A client is receiving oxygen at 4 L per nasal cannula what comfort measure may the nurse delegate to assistive personnel(AP)
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 below to deliver 50% O2 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
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 (SATA)
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 assistive personnel (SATA)
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 (SATA)
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 (SATA)
Cognition
Dexterity
Range of motion
Vision
Upper arm range of motion
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 (SATA)
Absorptive atelectasis
Combustion
Dried mucous membranes
Toxicity