Care of Patients Requiring Oxygen Therapy or Tracheostomy

Ensure informed consent is on the chart. This is essential before performing a tracheostomy, as it confirms that the client understands the procedure, its risks, and benefits, ensuring legal and ethical compliance. A: Administer prescribed anxiolytic medication. While managing anxiety is important, it does not address the need for legal consent prior to conducting the procedure. C: Reinforce any teaching done previously. While reinforcing prior education can be beneficial, it does not replace the necessity of confirming informed consent specifically for the upcoming tracheostomy. D: Start new teaching for the procedure. Initiating new teaching may be useful, but it cannot substitute the critical step of ensuring informed consent has been properly documented beforehand.

Assess the clients oxygen saturation. Monitoring oxygen saturation is critical for identifying potential respiratory distress or complications related to the tracheostomy. Swelling of the face and eyelids may indicate airway obstruction or compromised ventilation, necessitating immediate assessment of oxygen levels to ensure adequate oxygenation and prevent further complications. B: Notify the Rapid Response Team. This action, while important, is secondary to first evaluating the client's oxygen saturation, which directly impacts immediate patient safety and management. C: Oxygenate the client with a bag-valve-mask. This intervention could be necessary if the oxygen saturation is low, but it should follow an assessment to determine the client’s current respiratory status. D: Palpate the skin of the upper chest. Although skin assessment is vital in general care, it does not directly address the immediate concern of potential airway compromise or hypoxia indicated by facial swelling.

Elevating the head of the bed enhances respiratory function and reduces the risk of aspiration, thereby addressing complications associated with tracheostomy tubes. This position allows for easier airflow and decreases pressure on the cuff. A: Measure tracheostomy cuff pressures. While important, measuring pressures does not directly address the immediate issue of increased cuff pressure and its implications for the client’s safety. C: Place the client on NPO status. This action does not mitigate the concerns of cuff pressure and could unnecessarily limit the client’s intake, impacting their nutrition and hydration. D: Request that the client have a swallow study. A swallow study may be relevant for aspiration concerns but does not address the immediate problem of elevated cuff pressure impacting ventilation.

Assess the clients lung sounds. Prioritizing an assessment of the client's lung sounds is crucial after a coughing spell, as it helps identify potential complications such as aspiration or respiratory distress, which require immediate attention. This action ensures the nurse can promptly address any issues that may arise from the feeding process, thus safeguarding the client's wellbeing. B: Assign a different UAP to the client. Changing personnel does not address the immediate concern of the coughing spell and overlooks the necessity for a clinical assessment of the client's condition. C: Report the UAP to the manager. Reporting the UAP does not provide immediate care or resolution for the client experiencing respiratory issues, delaying necessary interventions that could prevent further complications. D: Request thicker liquids for meals. While modifying liquid consistency may help reduce aspiration risk in the future, it does not address the urgent need to assess the client's current respiratory status after the coughing incident.

C: Tying a square knot at the back of the neck. This technique can create tension on the tracheostomy tube, risking dislodgment or injury. Proper tie methods must ensure security without compromising the patient’s airway stability. A: Holding the device securely when changing ties. This action is essential for maintaining airway integrity during the tie change, ensuring safety and preventing accidental dislodgment of the tracheostomy tube. B: Suctioning the client first if secretions are present. This is a critical step in tracheostomy care, as it helps clear the airway, ensuring the patient can breathe effectively before any other interventions are performed. D: Assigning a ball through patient safety/nursing assessment. This choice lacks relevance to tracheostomy care procedures and does not address any specific nursing actions necessary for the patient’s safety and well-being.

Applying suction while inserting the catheter demonstrates that more teaching is needed. This action can cause trauma to the airway and reduce oxygenation, which contradicts best practices in tracheostomy care. B: Preoxygenating the client prior to suctioning This is a crucial step that enhances patient safety by ensuring adequate oxygen levels during the suctioning process, reflecting proper technique. C: Suctioning for a total of three times This practice aligns with guidelines that recommend limiting suction attempts to prevent hypoxia and airway damage, indicating the student understands safe procedures. D: Suctioning for only 10 to 15 seconds each time This duration is appropriate for minimizing airway irritation and maintaining patient safety, showcasing the student's comprehension of effective suctioning techniques.

Intact skin behind the ears indicates that the client is tolerating oxygen therapy well without developing any pressure injuries or irritation, which aligns with the goals of maintaining skin integrity during treatment. A: $100\%$ of meals being eaten by the client does not directly relate to oxygen therapy effectiveness or respiratory health, making it an irrelevant assessment finding for this situation. C: The client understanding the need for oxygen reflects knowledge but does not measure the actual physiological improvements or the effectiveness of the therapy on their condition. D: Unchanged weight for the past 3 days does not provide information about respiratory status or the effectiveness of the oxygen therapy, thus offering limited relevance to the client's overall health.

Stay with the client and have someone else call the provider immediately. This action ensures the client receives continuous monitoring and support while alerting the provider to the unusual finding, which may indicate potential complications requiring immediate intervention, safeguarding the client's health. A: Indicate to the provider a pending emergency case. This does not provide immediate support to the client, which is crucial when unusual signs are observed during nursing assessment. B: No action is needed at this time; this is a normal finding in some clients. Pulsation of the tracheostomy tube can indicate issues such as dislodgment or obstruction, warranting further evaluation. C: Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. Removing the tube could exacerbate the situation, as it may lead to airway compromise or distress for the client.

B: The client has joined a book club that meets at the library. This action reflects the client’s willingness to engage socially and pursue interests, indicating an improvement in self-esteem. Joining a community activity demonstrates confidence and a desire for connection, fulfilling the goals of the nursing diagnosis. A: The client demonstrates good understanding of stoma care. While knowledge of stoma care is important, it primarily reflects competence rather than self-esteem. Self-esteem involves personal feelings and social engagement rather than just technical understanding. C: Family members take turns assisting with stoma care. Family involvement signifies support but does not directly indicate the client’s self-esteem. It focuses more on external assistance rather than the client's personal confidence and social participation. D: Skin around the stoma is intact without signs of infection. This finding is related to physical health and stoma management, not self-esteem. It measures clinical outcomes rather than the client’s emotional and psychological well-being.

A: Apply water-soluble ointment to nares and lips. This action is a simple comfort measure that UAP can perform to alleviate dry nasal passages and lip discomfort, enhancing patient comfort while receiving oxygen therapy. B: Periodically turn the oxygen down or off. Adjusting oxygen levels requires clinical judgment and monitoring for patient safety, making it unsuitable for delegation to UAP. C: Remove the tubing from the clients nose. Discontinuing oxygen therapy should only be conducted by licensed personnel to ensure the patient’s respiratory needs are appropriately managed. D: Turn the client every 2 hours or as needed. Although positioning is important, it typically requires assessment of the patient’s condition, which UAP may not be qualified to evaluate.

Clients on home oxygen therapy must maintain a safe environment, making statements A, B, and C indicative of inadequate understanding. Smoking outside, while seemingly safer, still poses risks, while damaged cords and flammable liquids can lead to dangerous situations. A: My family members smoke outside the home. Even smoking outside can lead to dangerous fire hazards, as oxygen can still be present and create a risk of ignition. B: All my electrical cords are in good shape. While this suggests awareness of potential hazards, it does not address the critical need for ongoing inspections and replacements of cords used near oxygen sources. C: Flammable liquids are stored in the garage. Storing flammable liquids near oxygen therapy equipment creates a significant fire risk, as these substances can ignite easily in the presence of oxygen. D: Household light bulbs are the fluorescent type. Fluorescent bulbs do not pose a specific danger in relation to oxygen therapy, as they do not emit significant heat or sparks that could ignite fires. E: The client does not have pets inside the home. The absence of pets has no direct bearing on oxygen safety, as it primarily concerns environmental hazards related to fire and flammability.

A: Applying lip balm for the client and D: Reminding the client to cough and deep breathe often are appropriate tasks for unlicensed assistive personnel, as they involve basic care and support that do not require specialized nursing knowledge or skills. B: Ensuring the humidification provided is adequate demands assessment skills and critical thinking, which UAP are not trained to perform. C: Performing oral care with alcohol-based mouthwash requires awareness of client-specific needs and potential complications, unsuitable for UAP responsibility. E: Suctioning excess secretions through the tracheostomy involves advanced clinical skills and knowledge of sterile techniques, necessitating a licensed nurse's involvement for safety and efficacy.

A: Create a communication system. Establishing a communication method empowers the client, providing them with a sense of control and allowing them to express thoughts and feelings, thus enhancing self-esteem. B: Don't go out in public alone. This suggestion may foster dependency, undermining the client's confidence and ability to navigate social situations independently, which is essential for maintaining self-esteem. C: Try loose-fitting shirts with collars. Wearing comfortable, stylish clothing can boost the client’s confidence, allowing them to feel more at ease and presentable in social situations. D: Wear fashionable scarves. Incorporating accessories like scarves can help the client express their individuality and style, significantly enhancing their self-image and personal expression after the procedure.

The client’s cognition, dexterity, vision, and hydration are essential factors to assess before teaching tracheostomy care. These elements influence the client’s ability to understand, perform, and adhere to care instructions effectively. C: Range of motion does not directly relate to the client’s ability to comprehend or execute tracheostomy care, making it less relevant for teaching purposes. E: Hydration may impact overall health but does not specifically inform the client’s capability to learn or perform tracheostomy care tasks effectively.

Home oxygen therapy can lead to absorptive atelectasis, combustion, dried mucous membranes, oxygen-induced hyperventilation, and toxicity, all of which are important complications to consider for safe usage. A: Absorptive atelectasis can occur due to oxygen displacing nitrogen in the alveoli, leading to areas of lung collapse, which necessitates awareness during therapy. B: Combustion poses a significant risk with oxygen therapy, as increased oxygen concentration can ignite fires, making it crucial for clients to understand proper safety measures. C: Dried mucous membranes result from the drying effect of supplemental oxygen, which can compromise respiratory function and necessitate hydration strategies to maintain mucosal integrity. D: Oxygen-induced hyperventilation can happen when patients over-breathe due to excessive oxygen levels, leading to respiratory alkalosis and requiring monitoring of oxygen saturation. E: Toxicity may arise from prolonged exposure to high oxygen concentrations, potentially damaging lung tissue and emphasizing the importance of maintaining appropriate oxygen delivery levels.