MED SURG EXAM 2 EAQS
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Chapter 25: Concepts of Care for Pa... Pulmonary Part 1 Chapter 29 Critical Care of Pts with ... EAQs G
Teacher 60 terms 110 terms 53 terms 63 terms
moultonkayla26 Preview ellie323209 Preview Bamboo21496 Preview Jua
Which tracheotomy cuff pressure would the nurse 14 to 20 mmHg
maintain to prevent mucosal ischemia or air leakage?
-0 to 6 mmHg
-8 to 12 mmHg
-14 to 20 mmHg
-22 to 28 mmHg
After surgical placement of a tracheostomy tube, which -chest xray
method is recommended to verify correct placement?
-chest xray
-bronchosocpy
-symmetrical chest expansion
-auscultation of bilateral lung sounds
Which outcome is the purpose of removing the inner -the patient will be able to speak
cannula from a fenestrated tracheostomy tube?
-the patient will be able to speak
-the patient is able to swallow small sips of water
-the patien's full neck range of motion will be restored
-the patient will be weaned from the tracheostomy
A patient with a new tracheostomy has a soiled dressing. -replace the dressing with sterile, folded 4x4 guaze
What action would the nurse take?
-reinforce the dressing with sterile 4x4 guaze
-replace the dressing with clean fold 4x4 guaze
-replace the dressing with sterile, folded 4x4 guaze
-cut the sterile 4x4 guaze to fit around the track tube
Which factor is a sign of tracheoesophageal fistula? (TEF) -increasing coughing and choking while eating
-increased coughing and choking while eating
-clear and thin tracheal secretions
-recieving the set tidal volume on the ventilator
-decreasing air in the cuff needed to achieve a seal
,A patient has developed subcutaneous emphysema after -an opening or tear in the trachea is allowing air leakage into the tissues
surgery for a tracheostomy. Which situation explains why
the nurse would notify the health care provider
immediately?
-bleeding has occurred related to surgical incision;
hemoglobin is low
-ventilator pressures are too high, forcing air into tissue,
and must be lowered
-an opening or tear in the trachea is allowing air leakage
into the tissues
-the patient has a pneumothorax and will require a chest
tube for decompression
A patient who is concerned about getting a could you place a scarf or loose collar over it?
tracheostomy says "I will be ugly with a hole in my neck."
Which response would the nurse make?
-It won't take you long to learn to manage
-but you know you need to breathe right?
-your family and friends probably won't even care
-could you place a scarf or loose collar over it
Which info would the nurse include when teaching the thicken liquids, including water
patient with a new tracheostomy about preventing
aspiration?
-raise the head of bed 30 degrees when eating
-thickens liquids, including water
-when swallowing, raise the chin as though looking at the
ceiling
-if not already inflated, inflate the tube cuff when eating
or drinking
Which principle should guide the nurse's decision oral care is indicated to decrease the accumulation of organsims
regarding oral care for a patient with a tracheostomy
during the first 24 hours postoperative?
-providing oral care may damage the tracheostomy
stoma
-oral care is indicated to decrease the accumulation of
organsims
-if the patient is not taking oral nutrition, It is not a
concern at this time
-oral care is not indicated if the patient is being suctioned
on a regular basis
Which factor increases the risk for aspiration with the balloon interfering with food passage in the esophagus
tracheostomy tube in place?
-capping the tracheostomy tube for speaking
-amount of xerostomnia experienced by the patient
-the balloon interfering with food passage in the
esophagus
-increased length of time tracheostomy tube has been in
place
, Which information would the nurse include in the wear a loose-fitting scarf or decorative collar if you would like to minimize the
discharge teaching of a patient with a laryngectomy and appearance of the tube
tracheostomy?
-cover the airway loosely with plastic wrap when
showering
-use a dehumidifier in the home if secretions become
excessive
-wear a loose-fitting scarf or decorative collar if you
would like to minimize the appearance of the tube
-when coughing, place a finger over the tracheostomy to
expectorate secretions through the mouth
Which action would the nurse plan to take for an older keep the pressure on the tracheal tube between 14 and 20mmhg
patient with a tracheostomy who is receiving mechanical
ventilation?
-provide warm, humidified air, and suction the tube
hourly
-cut 4x4 guaze pads to place around stoma site
-keep the pressure on the tracheal tube between 14 and
20mmhg
-change the tracheotomy tube dressing and reposition
the tube every 4 Hours
Which oral hygiene product would the nurse recommend normal saline rinses
for a patient with a tracheostomy?
-glycerin swabs
-normal saline rinses
-hydrogen peroxide solutions
-mouthwash containing alcohol
Which medical emergency can lead to a life threatening trachea-innominate artery fistula
situation?
-tracheomalacia
-tracheal stenosis
-tracheoesophageal fistula (TEF)
-trachea-innominate artery fistula
Which action would the nurse plan to include in the care the pilot balloon should remain inflated
of a patient with a recently placed tracheostomy who is
on a mechanical ventilator?
-the pilot balloon should remain inflated
-a cuffed tube protects against aspiration
-a non cuffed tracheostomy tube is used
-the inner cannula is left out of the tube
A sedated patient with a new tracheostomy has noisy suction the patient
respirations and the ventilator alarms indicate high peak
pressures. Which action would the nurse take?
-suction the patient
-increase oxygenation
-humidifiy the oxygen source
-remove inner cannula
Save
Students also studied
Chapter 25: Concepts of Care for Pa... Pulmonary Part 1 Chapter 29 Critical Care of Pts with ... EAQs G
Teacher 60 terms 110 terms 53 terms 63 terms
moultonkayla26 Preview ellie323209 Preview Bamboo21496 Preview Jua
Which tracheotomy cuff pressure would the nurse 14 to 20 mmHg
maintain to prevent mucosal ischemia or air leakage?
-0 to 6 mmHg
-8 to 12 mmHg
-14 to 20 mmHg
-22 to 28 mmHg
After surgical placement of a tracheostomy tube, which -chest xray
method is recommended to verify correct placement?
-chest xray
-bronchosocpy
-symmetrical chest expansion
-auscultation of bilateral lung sounds
Which outcome is the purpose of removing the inner -the patient will be able to speak
cannula from a fenestrated tracheostomy tube?
-the patient will be able to speak
-the patient is able to swallow small sips of water
-the patien's full neck range of motion will be restored
-the patient will be weaned from the tracheostomy
A patient with a new tracheostomy has a soiled dressing. -replace the dressing with sterile, folded 4x4 guaze
What action would the nurse take?
-reinforce the dressing with sterile 4x4 guaze
-replace the dressing with clean fold 4x4 guaze
-replace the dressing with sterile, folded 4x4 guaze
-cut the sterile 4x4 guaze to fit around the track tube
Which factor is a sign of tracheoesophageal fistula? (TEF) -increasing coughing and choking while eating
-increased coughing and choking while eating
-clear and thin tracheal secretions
-recieving the set tidal volume on the ventilator
-decreasing air in the cuff needed to achieve a seal
,A patient has developed subcutaneous emphysema after -an opening or tear in the trachea is allowing air leakage into the tissues
surgery for a tracheostomy. Which situation explains why
the nurse would notify the health care provider
immediately?
-bleeding has occurred related to surgical incision;
hemoglobin is low
-ventilator pressures are too high, forcing air into tissue,
and must be lowered
-an opening or tear in the trachea is allowing air leakage
into the tissues
-the patient has a pneumothorax and will require a chest
tube for decompression
A patient who is concerned about getting a could you place a scarf or loose collar over it?
tracheostomy says "I will be ugly with a hole in my neck."
Which response would the nurse make?
-It won't take you long to learn to manage
-but you know you need to breathe right?
-your family and friends probably won't even care
-could you place a scarf or loose collar over it
Which info would the nurse include when teaching the thicken liquids, including water
patient with a new tracheostomy about preventing
aspiration?
-raise the head of bed 30 degrees when eating
-thickens liquids, including water
-when swallowing, raise the chin as though looking at the
ceiling
-if not already inflated, inflate the tube cuff when eating
or drinking
Which principle should guide the nurse's decision oral care is indicated to decrease the accumulation of organsims
regarding oral care for a patient with a tracheostomy
during the first 24 hours postoperative?
-providing oral care may damage the tracheostomy
stoma
-oral care is indicated to decrease the accumulation of
organsims
-if the patient is not taking oral nutrition, It is not a
concern at this time
-oral care is not indicated if the patient is being suctioned
on a regular basis
Which factor increases the risk for aspiration with the balloon interfering with food passage in the esophagus
tracheostomy tube in place?
-capping the tracheostomy tube for speaking
-amount of xerostomnia experienced by the patient
-the balloon interfering with food passage in the
esophagus
-increased length of time tracheostomy tube has been in
place
, Which information would the nurse include in the wear a loose-fitting scarf or decorative collar if you would like to minimize the
discharge teaching of a patient with a laryngectomy and appearance of the tube
tracheostomy?
-cover the airway loosely with plastic wrap when
showering
-use a dehumidifier in the home if secretions become
excessive
-wear a loose-fitting scarf or decorative collar if you
would like to minimize the appearance of the tube
-when coughing, place a finger over the tracheostomy to
expectorate secretions through the mouth
Which action would the nurse plan to take for an older keep the pressure on the tracheal tube between 14 and 20mmhg
patient with a tracheostomy who is receiving mechanical
ventilation?
-provide warm, humidified air, and suction the tube
hourly
-cut 4x4 guaze pads to place around stoma site
-keep the pressure on the tracheal tube between 14 and
20mmhg
-change the tracheotomy tube dressing and reposition
the tube every 4 Hours
Which oral hygiene product would the nurse recommend normal saline rinses
for a patient with a tracheostomy?
-glycerin swabs
-normal saline rinses
-hydrogen peroxide solutions
-mouthwash containing alcohol
Which medical emergency can lead to a life threatening trachea-innominate artery fistula
situation?
-tracheomalacia
-tracheal stenosis
-tracheoesophageal fistula (TEF)
-trachea-innominate artery fistula
Which action would the nurse plan to include in the care the pilot balloon should remain inflated
of a patient with a recently placed tracheostomy who is
on a mechanical ventilator?
-the pilot balloon should remain inflated
-a cuffed tube protects against aspiration
-a non cuffed tracheostomy tube is used
-the inner cannula is left out of the tube
A sedated patient with a new tracheostomy has noisy suction the patient
respirations and the ventilator alarms indicate high peak
pressures. Which action would the nurse take?
-suction the patient
-increase oxygenation
-humidifiy the oxygen source
-remove inner cannula
