ADN210 TRACH NCLEX PRACTICE
QUESTIONS AND ANSWERS
/. The nurse is caring for a client with a new tracheostomy. Which assessment finding
requires the nurse's immediate action:
A-Cuff pressure readings consistently between 14 and 20 mm Hg.
B-Need to change Velcro tube holders three times in 1 day.
C-Checking sensation around the neck when skin is palpated.
D-Small amount of bleeding around the incision for the first few days. - Answer-C
/.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-Rhonchi in upper lobes
D-Dry mucous membranes. - Answer-A
/.A client has been placed on 6 L of humidified oxygen via nasal cannula. Which action
by the nurse is most appropriate?
A-Drain condensation back into the humidifier, maintaining a closed system.
B-Keep the water sterile by draining it from the water trap back into the humidifier,
maintaining a closed system.
C-Turn down the humidity when condensation begins to collect in the tubing.
D-Remove condensation in the tubing by disconnecting and emptying it appropriately. -
Answer-D
/.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?
A-"Tell people how sick you were when they ask about the tracheostomy."
B-"Your clothing can help hide the tracheostomy so it is not as noticeable."
C-"You can put a bandage around your tracheostomy so no one will see it."
D-"You have to ignore comments that people make about your appearance." - Answer-
B
/.A client is becoming frustrated because of an inability to communicate with a
tracheostomy. Which intervention by the nurse most effectively enhances
communication?
, A-Explain to the client that speech will be clear and distinct with a fenestrated tube.
B-Reassure the client that in time he or she will get used to the speech difficulties.
C-Place a sign above the client's bed indicating that the client cannot s peak.
D-Provide the client with a communication board and call light within easy reach. -
Answer-D
/.A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds
the client cyanotic with labored respirations. Which action does the nurse perform first?
A-Remove bedding from around the adaptor opening.
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. - Answer-A
/.A client requires oxygen received via face mask but wants to remain as mobile as
possible once discharged home. Which interventions by the home health nurse best
provides the client with maximal mobility?
A-Arrange a consultation with pulmonary rehabilitation to decrease oxygen needs.
B-Encourage the client to remove the mask occasionally to assess tolerance.
C-Add extra connecting pieces of tubing to the client's existing oxygen setup.
D-Change the face mask to nasal cannula occasionally, such as at mealtimes. -
Answer-C
/.A client has been brought in by the rescue squad to the emergency department. The
client is having an acute exacerbation of chronic obstructive pulmonary disease (COPD)
and is severely short of breath. On arrival, the client is on 15 L/min of oxygenation via
rebreather mask. Which action by the nurse takes priority?
A-Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cannula.
B-Perform a thorough respiratory assessment and attach pulse oximetry.
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 oxygen down. - Answer-B
/.The nurse is caring for a client with orders for oxygen at 5 L/min. Approximately how
much FiO2 is the client receiving?
A-24%
B-28%
C-36%
D-40% - Answer-D
/.A client who is receiving continuous oxygen therapy by nasal cannula for an acute
respiratory problem is becoming increasingly confused. What does the nurse do first?
A-Notify the health care provider.
QUESTIONS AND ANSWERS
/. The nurse is caring for a client with a new tracheostomy. Which assessment finding
requires the nurse's immediate action:
A-Cuff pressure readings consistently between 14 and 20 mm Hg.
B-Need to change Velcro tube holders three times in 1 day.
C-Checking sensation around the neck when skin is palpated.
D-Small amount of bleeding around the incision for the first few days. - Answer-C
/.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-Rhonchi in upper lobes
D-Dry mucous membranes. - Answer-A
/.A client has been placed on 6 L of humidified oxygen via nasal cannula. Which action
by the nurse is most appropriate?
A-Drain condensation back into the humidifier, maintaining a closed system.
B-Keep the water sterile by draining it from the water trap back into the humidifier,
maintaining a closed system.
C-Turn down the humidity when condensation begins to collect in the tubing.
D-Remove condensation in the tubing by disconnecting and emptying it appropriately. -
Answer-D
/.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?
A-"Tell people how sick you were when they ask about the tracheostomy."
B-"Your clothing can help hide the tracheostomy so it is not as noticeable."
C-"You can put a bandage around your tracheostomy so no one will see it."
D-"You have to ignore comments that people make about your appearance." - Answer-
B
/.A client is becoming frustrated because of an inability to communicate with a
tracheostomy. Which intervention by the nurse most effectively enhances
communication?
, A-Explain to the client that speech will be clear and distinct with a fenestrated tube.
B-Reassure the client that in time he or she will get used to the speech difficulties.
C-Place a sign above the client's bed indicating that the client cannot s peak.
D-Provide the client with a communication board and call light within easy reach. -
Answer-D
/.A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds
the client cyanotic with labored respirations. Which action does the nurse perform first?
A-Remove bedding from around the adaptor opening.
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. - Answer-A
/.A client requires oxygen received via face mask but wants to remain as mobile as
possible once discharged home. Which interventions by the home health nurse best
provides the client with maximal mobility?
A-Arrange a consultation with pulmonary rehabilitation to decrease oxygen needs.
B-Encourage the client to remove the mask occasionally to assess tolerance.
C-Add extra connecting pieces of tubing to the client's existing oxygen setup.
D-Change the face mask to nasal cannula occasionally, such as at mealtimes. -
Answer-C
/.A client has been brought in by the rescue squad to the emergency department. The
client is having an acute exacerbation of chronic obstructive pulmonary disease (COPD)
and is severely short of breath. On arrival, the client is on 15 L/min of oxygenation via
rebreather mask. Which action by the nurse takes priority?
A-Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cannula.
B-Perform a thorough respiratory assessment and attach pulse oximetry.
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 oxygen down. - Answer-B
/.The nurse is caring for a client with orders for oxygen at 5 L/min. Approximately how
much FiO2 is the client receiving?
A-24%
B-28%
C-36%
D-40% - Answer-D
/.A client who is receiving continuous oxygen therapy by nasal cannula for an acute
respiratory problem is becoming increasingly confused. What does the nurse do first?
A-Notify the health care provider.
