CHAPTER 30: CARE OF PATIENTS Minimize how long the tubing is disconnected because the client
does not receive oxygen during this period.
REQUIRING OXYGEN THERAPY OR
TRACHEOSTOMY
TEST BANK 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?
MULTIPLE CHOICE a. “Tell people how sick you were when they ask about
tracheostomy.
b. “Your clothing can help hide the tracheostomy so it is no
noticeable
1. The nurse is caring for a client with a new tracheostomy. Which c. “You can put a bandage around your tracheostomy so no one will
i
assessment finding requires the nurse’s immediate action? d. “You have to ignore comments that people make about y
appearanc
a. Cuff pressure readings consistently between 14 and 20 mm
Hg. ANS: B
b. Need to change Velcro tube holders three times in 1 day. The client may have an alteration in body image because of the
c. Crackling sensation around the neck when skin is palpated.
t r a c heostomy stoma. Encourage the client to wear loose-fitting
d. Small amount of bleeding around the incision for the first few d a y s .
shirts and collars to help hide the appearance of the stoma. Clients
ANS: C should not be encouraged to tell people about their illness, because
Subcutaneous emphysema occurs when an opening or tear occurs they should not be made to “justify” their appearance. You should
in the trachea and air escapes into fresh tissue planes of the neck. not bandage the tracheostomy, because airflow would be
Air can also progress through the chest and other tissues into the impaired. Ignoring comments will not help the client’s self-image.
face. Inspect and palpate for air under the skin around the new
tracheostomy. If the skin is puffy and you can feel a 5. A client is becoming frustrated because of an inability to
crackling
sensation, notify the physician immediately. Cuff pressures should communicate with a tracheostomy. Which intervention by the
be maintained between 14 and 20 mm Hg or between 20 and 28 nurse most effectively enhances communication?
cm H2O. Tracheostomy ties need to be changed at least once a day
a. Explain to the client that speech will be clear and distinct with a
or
fenest
whenever soiled. It is not uncommon for a client with a new b. Reassure the client that in time he or she will get used to the spee
dif
tracheostomy to have heavy secretions that would necessitate c. Rhonchi in upper lobes
changing them. It is not unusual to have a small amount of d. Dry mucous membranes
bleeding around the incision for the first few days after
surgical placement. ANS: A
Causes and manifestations of lung injury from oxygen toxicity
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. Place a sign above the client’s bed indicating that the client doubtful that the client with a tracheostomy will ever speak clearly
cannot spe and distinctly, no matter what type of tube he or she uses.
d. Provide the client with a communication board and call light Reassuring the client that he or she will get used to the speech
within ea difficulties does nothing to alleviate the discomfort and fear
associated with impaired communication. Placing a sign above the
ANS: D client’s bed indicating that he cannot speak will not enhance his
A communication board and the call light will reassure the ability to communicate, although it may help staff remember that
client that needs will be communicated and met. It is the client has impaired communication.
include nonproductive cough, substernal chest pain, GI upset, and6. A client is receiving oxygen via Venturi mask at 40%. On
dyspnea. Blood-tinged sputum is expected in clients with new assessment the nurse finds the client cyanotic with labored
tracheostomies. Rhonchi in upper lobes indicates sputum that respirations. Which action does the nurse perform first?
can be expectorated and is not an emergent problem. Dry
mucous membranes should be lubricated, and the client’s a. Remove bedding from around the adaptor opening.
hydration status can be checked. 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.
3. A client has been placed on 6 L of humidified oxygen via nasal
cannula. Which action by the nurse is most appropriate?
, ANS: A
a. Drain condensation back into the humidifier, maintaining a closTedhesyVsetenmtu.ri mask works by drawing in a specific amount of ai
b. Keep the water sterile by draining it from the water trap back inmtoixthwe ihtuhmthiediofixeyr.gen through holes in an adaptor fitte
the
c. Turn down the humidity when condensation begins to collect inbtohtetotmubionfgt.he mask. Holes of different sizes allow different
a m ou n ts o f r o o m a ir to be entrained, changing
d. Remove condensation in the tubing by disconnecting and empty i ng it a pp r o p r ia te ly .
amount of
oxygen delivered. Bedding (or clothing) wrapped around those
ANS: D holes would effectively change the FiO2. The nurse should ensure
Condensation often forms in the tubing when a client receives that the holes remain unobstructed. Other options are appropriate
humidified high-flow oxygen. Remove this condensation as it but are not the first choice, because this simple step may be what
collects by disconnecting the tubing and emptying the water. solves the problem.
Some humidifiers and nebulizers have a water trap that hangs
from the
tubing so the condensation can be drained without disconnecting.7. A client requires oxygen received via a face mask but wants to
To prevent bacterial contamination, never drain the fluid back remain as mobile as possible once discharged home. Which
into the humidifier or the nebulizer. Do not turn down the intervention by the home health nurse best provides the client with
humidity because the physician has ordered it and the client needs maximal mobility?
it.
, a. Arrange a consultation with pulmonary rehabilitation to decreasCeeorxeybgraelnhnyepeodxsi.a is a cause of confusion and is a sensitiv
b. Encourage the client to remove the mask occasionally to assess itnodleicrantocret.hat the client needs more oxygen. Although you wo
c. Add extra connecting pieces of tubing to the client’s existing oxwygaennt tsoetnuopt.ify the provider of the change in the clie
condition,
d. Change the face mask to a nasal cannula occasionally, such as atthme ebaelsttimacetsi.on is first to assess pulse oximetry and then
increase
the oxygen. You would not just document the assessment finding
ANS: C without intervening. Raising the head of the bed would not help the
To increase mobility, up to 50 feet of connecting tubing can be client oxygenate better.
used with connecting pieces. A client with a chronic
respiratory condition needing home oxygen may not be able to
decrease 11. The nurse assesses a client who is receiving oxygen via a partial
oxygen needs through pulmonary rehabilitation, but that would rebreather mask. Which assessment finding does the
not increase mobility with an oxygen device. The nurse should not nurse intervene to correct?
independently encourage the client to remove the mask for periods
of time or change to a cannula. 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.
8. A client has been brought in by the rescue squad to the d. The arterial oxygen level is 90%.
emergency department. The client is having an acute
exacerbation of chronic obstructive pulmonary disease (COPD) ANS: C
and is severely short of breath. On arrival, the client is on 15 Flow rate should be 6 to 11 L/min. A flow rate of 2 L/min will not
L/min of oxygen via rebreather mask. Which action by the nurse adequately inflate the bag. A bag that is two thirds inflated is
takes priority?
a. Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cdanesniurelad.. A pulse oximetry reading of 93% and higher is adequate
b. Perform a thorough respiratory assessment and attach pulse oximaseitsrya.n arterial oxygenation of 90%.
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 oxy1g2e.n dAowclnie. nt is to be discharged home on oxygen therapy. What
information does the nurse teach the client?
ANS: B a. “Carry the H cylinder tank on short trips.”
Oxygen-induced hypoventilation can occur in clients with b. “Only use the E tank when stationary.”
chronically elevated PCO2 levels, such as those seen in COPD. “The D or C cylinder can be carried.”
c.
Giving oxygen can eliminate their hypoxic drive to breathe and can
d. “Roll the tank gently when transporting.”
cause respiratory arrest. However, hypoxemia is a greater threat to
an acutely ill client than is the potential for oxygen-induced ANS: C
hypoventilation, and clients should be given the amount of oxygen The D and C cylinders are small enough to be carried. The H
they require. The nurse should perform a thorough respiratory cylinder cannot be carried. The E tank can be transported. The
assessment and should monitor the client for signs of this problem, tanks should not be rolled and should be carried only in a stand or
rather than automatically reducing oxygen delivery. Blood gases a rack.
and a chest x-ray will also be obtained, but they do not take priority
over assessing and monitoring the client. 13. The nurse assesses a client with a new tracheotomy, and the
tracheostomy tube is pulsating in synchrony with the
client’s
9. The nurse is caring for a client with orders for oxygen at 5 L/min. d. 40%
Approximately how much FiO2 is the client receiving? ANS: D
24% A nasal cannula can provide oxygen at 0.5 to 6 L/min
a.
corresponding to an FiO2 range of 25% to 40%. At 5 L/min, th
b. 28% client is receiving 40% oxygen.
c. 36%
does not receive oxygen during this period.
REQUIRING OXYGEN THERAPY OR
TRACHEOSTOMY
TEST BANK 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?
MULTIPLE CHOICE a. “Tell people how sick you were when they ask about
tracheostomy.
b. “Your clothing can help hide the tracheostomy so it is no
noticeable
1. The nurse is caring for a client with a new tracheostomy. Which c. “You can put a bandage around your tracheostomy so no one will
i
assessment finding requires the nurse’s immediate action? d. “You have to ignore comments that people make about y
appearanc
a. Cuff pressure readings consistently between 14 and 20 mm
Hg. ANS: B
b. Need to change Velcro tube holders three times in 1 day. The client may have an alteration in body image because of the
c. Crackling sensation around the neck when skin is palpated.
t r a c heostomy stoma. Encourage the client to wear loose-fitting
d. Small amount of bleeding around the incision for the first few d a y s .
shirts and collars to help hide the appearance of the stoma. Clients
ANS: C should not be encouraged to tell people about their illness, because
Subcutaneous emphysema occurs when an opening or tear occurs they should not be made to “justify” their appearance. You should
in the trachea and air escapes into fresh tissue planes of the neck. not bandage the tracheostomy, because airflow would be
Air can also progress through the chest and other tissues into the impaired. Ignoring comments will not help the client’s self-image.
face. Inspect and palpate for air under the skin around the new
tracheostomy. If the skin is puffy and you can feel a 5. A client is becoming frustrated because of an inability to
crackling
sensation, notify the physician immediately. Cuff pressures should communicate with a tracheostomy. Which intervention by the
be maintained between 14 and 20 mm Hg or between 20 and 28 nurse most effectively enhances communication?
cm H2O. Tracheostomy ties need to be changed at least once a day
a. Explain to the client that speech will be clear and distinct with a
or
fenest
whenever soiled. It is not uncommon for a client with a new b. Reassure the client that in time he or she will get used to the spee
dif
tracheostomy to have heavy secretions that would necessitate c. Rhonchi in upper lobes
changing them. It is not unusual to have a small amount of d. Dry mucous membranes
bleeding around the incision for the first few days after
surgical placement. ANS: A
Causes and manifestations of lung injury from oxygen toxicity
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. Place a sign above the client’s bed indicating that the client doubtful that the client with a tracheostomy will ever speak clearly
cannot spe and distinctly, no matter what type of tube he or she uses.
d. Provide the client with a communication board and call light Reassuring the client that he or she will get used to the speech
within ea difficulties does nothing to alleviate the discomfort and fear
associated with impaired communication. Placing a sign above the
ANS: D client’s bed indicating that he cannot speak will not enhance his
A communication board and the call light will reassure the ability to communicate, although it may help staff remember that
client that needs will be communicated and met. It is the client has impaired communication.
include nonproductive cough, substernal chest pain, GI upset, and6. A client is receiving oxygen via Venturi mask at 40%. On
dyspnea. Blood-tinged sputum is expected in clients with new assessment the nurse finds the client cyanotic with labored
tracheostomies. Rhonchi in upper lobes indicates sputum that respirations. Which action does the nurse perform first?
can be expectorated and is not an emergent problem. Dry
mucous membranes should be lubricated, and the client’s a. Remove bedding from around the adaptor opening.
hydration status can be checked. 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.
3. A client has been placed on 6 L of humidified oxygen via nasal
cannula. Which action by the nurse is most appropriate?
, ANS: A
a. Drain condensation back into the humidifier, maintaining a closTedhesyVsetenmtu.ri mask works by drawing in a specific amount of ai
b. Keep the water sterile by draining it from the water trap back inmtoixthwe ihtuhmthiediofixeyr.gen through holes in an adaptor fitte
the
c. Turn down the humidity when condensation begins to collect inbtohtetotmubionfgt.he mask. Holes of different sizes allow different
a m ou n ts o f r o o m a ir to be entrained, changing
d. Remove condensation in the tubing by disconnecting and empty i ng it a pp r o p r ia te ly .
amount of
oxygen delivered. Bedding (or clothing) wrapped around those
ANS: D holes would effectively change the FiO2. The nurse should ensure
Condensation often forms in the tubing when a client receives that the holes remain unobstructed. Other options are appropriate
humidified high-flow oxygen. Remove this condensation as it but are not the first choice, because this simple step may be what
collects by disconnecting the tubing and emptying the water. solves the problem.
Some humidifiers and nebulizers have a water trap that hangs
from the
tubing so the condensation can be drained without disconnecting.7. A client requires oxygen received via a face mask but wants to
To prevent bacterial contamination, never drain the fluid back remain as mobile as possible once discharged home. Which
into the humidifier or the nebulizer. Do not turn down the intervention by the home health nurse best provides the client with
humidity because the physician has ordered it and the client needs maximal mobility?
it.
, a. Arrange a consultation with pulmonary rehabilitation to decreasCeeorxeybgraelnhnyepeodxsi.a is a cause of confusion and is a sensitiv
b. Encourage the client to remove the mask occasionally to assess itnodleicrantocret.hat the client needs more oxygen. Although you wo
c. Add extra connecting pieces of tubing to the client’s existing oxwygaennt tsoetnuopt.ify the provider of the change in the clie
condition,
d. Change the face mask to a nasal cannula occasionally, such as atthme ebaelsttimacetsi.on is first to assess pulse oximetry and then
increase
the oxygen. You would not just document the assessment finding
ANS: C without intervening. Raising the head of the bed would not help the
To increase mobility, up to 50 feet of connecting tubing can be client oxygenate better.
used with connecting pieces. A client with a chronic
respiratory condition needing home oxygen may not be able to
decrease 11. The nurse assesses a client who is receiving oxygen via a partial
oxygen needs through pulmonary rehabilitation, but that would rebreather mask. Which assessment finding does the
not increase mobility with an oxygen device. The nurse should not nurse intervene to correct?
independently encourage the client to remove the mask for periods
of time or change to a cannula. 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.
8. A client has been brought in by the rescue squad to the d. The arterial oxygen level is 90%.
emergency department. The client is having an acute
exacerbation of chronic obstructive pulmonary disease (COPD) ANS: C
and is severely short of breath. On arrival, the client is on 15 Flow rate should be 6 to 11 L/min. A flow rate of 2 L/min will not
L/min of oxygen via rebreather mask. Which action by the nurse adequately inflate the bag. A bag that is two thirds inflated is
takes priority?
a. Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cdanesniurelad.. A pulse oximetry reading of 93% and higher is adequate
b. Perform a thorough respiratory assessment and attach pulse oximaseitsrya.n arterial oxygenation of 90%.
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 oxy1g2e.n dAowclnie. nt is to be discharged home on oxygen therapy. What
information does the nurse teach the client?
ANS: B a. “Carry the H cylinder tank on short trips.”
Oxygen-induced hypoventilation can occur in clients with b. “Only use the E tank when stationary.”
chronically elevated PCO2 levels, such as those seen in COPD. “The D or C cylinder can be carried.”
c.
Giving oxygen can eliminate their hypoxic drive to breathe and can
d. “Roll the tank gently when transporting.”
cause respiratory arrest. However, hypoxemia is a greater threat to
an acutely ill client than is the potential for oxygen-induced ANS: C
hypoventilation, and clients should be given the amount of oxygen The D and C cylinders are small enough to be carried. The H
they require. The nurse should perform a thorough respiratory cylinder cannot be carried. The E tank can be transported. The
assessment and should monitor the client for signs of this problem, tanks should not be rolled and should be carried only in a stand or
rather than automatically reducing oxygen delivery. Blood gases a rack.
and a chest x-ray will also be obtained, but they do not take priority
over assessing and monitoring the client. 13. The nurse assesses a client with a new tracheotomy, and the
tracheostomy tube is pulsating in synchrony with the
client’s
9. The nurse is caring for a client with orders for oxygen at 5 L/min. d. 40%
Approximately how much FiO2 is the client receiving? ANS: D
24% A nasal cannula can provide oxygen at 0.5 to 6 L/min
a.
corresponding to an FiO2 range of 25% to 40%. At 5 L/min, th
b. 28% client is receiving 40% oxygen.
c. 36%
