lOMoARcPSD|8771298
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 220
Chapter 28: Care of Patients Requiring Oxygen Therapy or
Tracheostomy
MULTIPLE CHOICE
1. A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing
what percentage of oxygen in the room air?
a. 14%
b. 21%
c. 28%
d. 31%
ANS: B
Room air is 21% oxygen.
DIF: Remembering/Knowledge REF: 529
KEY: Oxygen| physiology
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
a. Administer prescribed anxiolytic medication.
b. Ensure informed consent is on the chart.
c. Reinforce any teaching done previously.
d. Start the preoperative antibiotic infusion.
ANS: B
Since this is an operative procedure, the client must sign an informed consent, which must be on the chart.
Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.
DIF: Applying/Application REF: 537
KEY: Informed consent| autonomy
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and
the eyelids are swollen. What action by the nurse takes priority?
a. Assess the clients oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest.
ANS: A
This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the
tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation.
If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable,
the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for
the unstable client.
DIF: Applying/Application REF: 538
KEY: Oxygenation| tracheostomy| nursing assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What
action by the nurse is best?
a. Elevate the head of the clients bed.
b. Measure and compare cuff pressures.
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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 221
c. Place the client on NPO status.
d. Request that the client have a swallow study.
ANS: B
Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal
passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts
of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and
compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO
status, and requesting a swallow study will not correct this situation.
DIF: Analyzing/Analysis REF: 538
KEY: Tracheostomy| patient safety| nursing assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the
UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?
a. Assess the clients lung sounds.
b. Assign a different UAP to the client.
c. Report the UAP to the manager.
d. Request thicker liquids for meals.
ANS: A
The priority is to check the clients oxygenation because he or she may have aspirated. Once the client has been
assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP
should have reported the incident immediately, but addressing that issue is not the immediate priority.
DIF: Applying/Application REF: 539
KEY: Delegation| aspiration| tracheostomy| nursing assessment| unlicensed assistive personnel (UAP) MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A student nurse is providing tracheostomy care. What action by the student requires intervention by the
instructor?
a. Holding the device securely when changing ties
b. Suctioning the client first if secretions are present
c. Tying a square knot at the back of the neck
d. Using half-strength peroxide for cleansing
ANS: C
To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot should be
placed at the side of the clients neck, not in back. The other actions are appropriate.
DIF: Applying/Application REF: 542
KEY: Tracheostomy| tracheostomy care| patient safety| supervision
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student
demonstrates that more teaching is needed?
a. Applying suction while inserting the catheter
b. Preoxygenating the client prior to suctioning
c. Suctioning for a total of three times if needed
d. Suctioning for only 10 to 15 seconds each time
ANS: A
Suction should only be applied while withdrawing the catheter. The other actions are appropriate.
DIF: Remembering/Knowledge REF: 540
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Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 220
Chapter 28: Care of Patients Requiring Oxygen Therapy or
Tracheostomy
MULTIPLE CHOICE
1. A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing
what percentage of oxygen in the room air?
a. 14%
b. 21%
c. 28%
d. 31%
ANS: B
Room air is 21% oxygen.
DIF: Remembering/Knowledge REF: 529
KEY: Oxygen| physiology
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
a. Administer prescribed anxiolytic medication.
b. Ensure informed consent is on the chart.
c. Reinforce any teaching done previously.
d. Start the preoperative antibiotic infusion.
ANS: B
Since this is an operative procedure, the client must sign an informed consent, which must be on the chart.
Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.
DIF: Applying/Application REF: 537
KEY: Informed consent| autonomy
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and
the eyelids are swollen. What action by the nurse takes priority?
a. Assess the clients oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest.
ANS: A
This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the
tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation.
If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable,
the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for
the unstable client.
DIF: Applying/Application REF: 538
KEY: Oxygenation| tracheostomy| nursing assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What
action by the nurse is best?
a. Elevate the head of the clients bed.
b. Measure and compare cuff pressures.
Downloaded by Denhow Deanz ()
, lOMoARcPSD|8771298
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 221
c. Place the client on NPO status.
d. Request that the client have a swallow study.
ANS: B
Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal
passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts
of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and
compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO
status, and requesting a swallow study will not correct this situation.
DIF: Analyzing/Analysis REF: 538
KEY: Tracheostomy| patient safety| nursing assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the
UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?
a. Assess the clients lung sounds.
b. Assign a different UAP to the client.
c. Report the UAP to the manager.
d. Request thicker liquids for meals.
ANS: A
The priority is to check the clients oxygenation because he or she may have aspirated. Once the client has been
assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP
should have reported the incident immediately, but addressing that issue is not the immediate priority.
DIF: Applying/Application REF: 539
KEY: Delegation| aspiration| tracheostomy| nursing assessment| unlicensed assistive personnel (UAP) MSC:
Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A student nurse is providing tracheostomy care. What action by the student requires intervention by the
instructor?
a. Holding the device securely when changing ties
b. Suctioning the client first if secretions are present
c. Tying a square knot at the back of the neck
d. Using half-strength peroxide for cleansing
ANS: C
To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot should be
placed at the side of the clients neck, not in back. The other actions are appropriate.
DIF: Applying/Application REF: 542
KEY: Tracheostomy| tracheostomy care| patient safety| supervision
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student
demonstrates that more teaching is needed?
a. Applying suction while inserting the catheter
b. Preoxygenating the client prior to suctioning
c. Suctioning for a total of three times if needed
d. Suctioning for only 10 to 15 seconds each time
ANS: A
Suction should only be applied while withdrawing the catheter. The other actions are appropriate.
DIF: Remembering/Knowledge REF: 540
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