Chapter 25: Concepts of Care for Patients
Requiring Oxygen Therapy or Tracheostomy
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is caring for a client using oxygen while in the hospital. What assessment
finding indicates that outcomes for client safety with oxygen therapy are being met?
a. 100% of meals being eaten by the client
b. Intact skin behind the ears
c. The client understanding the need for oxygen
d. Unchanged weight for the past 3 days
ANS: B
Oxygen tubing can cause pressure injuries, so clients using oxygen have a high risk of
skin breakdown. Intact skin behind the ears indicates that goals for maintaining client
safety with oxygen therapy are being met. Nutrition and weight are not related to
using oxygen. Understanding the need for oxygen is important but would not take
priority over a physical problem.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation
KEY: Oxygen therapy, Skin integrity MSC: Client Needs
Category: Physiological Integrity: Reduction of Risk Potential
2. A nurse is assessing a client who has a tracheostomy. The nurse notes that the
tracheostomy tube is pulsing with the heartbeat as the client’s pulse is being taken. No
other abnormal findings are noted. What action by the nurse is most appropriate?
a. Call the operating room to inform them of a pending emergency case.
, b. No action is needed at this time; this is a normal finding in some clients.
c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
d. Stay with the client and have someone else call the primary health care
provider immediately.
ANS: D
This client may have a tracheoinnominate artery fistula, which can be a life-
threatening emergency if the artery is breached and the client begins to hemorrhage.
Since no bleeding is yet present, the nurse stays with the client and asks someone else
to notify the primary health care provider. If the client begins hemorrhaging, the nurse
removes the tracheostomy and applies pressure at the bleeding site. The client will
need to be prepared for surgery.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Tracheostomy, Medical emergencies
MSC: Client Needs Category: Physiological Integrity: Physiological
Adaptation
3. A client with a new tracheostomy is being seen in the oncology clinic. What finding
by the nurse best indicates that goals for the client’s decrease in self-esteem are being
met?
a. The client demonstrates good understanding of stoma care.
b. The client has joined a book club that meets at the library.
c. Family members take turns assisting with stoma care.
d. Skin around the stoma is intact without signs of infection.
ANS: B
The client joining a book club that meets outside the home and requires him or her to
go out in public is the best sign that goals for disrupted self-esteem are being met. The
other findings are all positive signs but do not relate to this client problem.
Requiring Oxygen Therapy or Tracheostomy
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is caring for a client using oxygen while in the hospital. What assessment
finding indicates that outcomes for client safety with oxygen therapy are being met?
a. 100% of meals being eaten by the client
b. Intact skin behind the ears
c. The client understanding the need for oxygen
d. Unchanged weight for the past 3 days
ANS: B
Oxygen tubing can cause pressure injuries, so clients using oxygen have a high risk of
skin breakdown. Intact skin behind the ears indicates that goals for maintaining client
safety with oxygen therapy are being met. Nutrition and weight are not related to
using oxygen. Understanding the need for oxygen is important but would not take
priority over a physical problem.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation
KEY: Oxygen therapy, Skin integrity MSC: Client Needs
Category: Physiological Integrity: Reduction of Risk Potential
2. A nurse is assessing a client who has a tracheostomy. The nurse notes that the
tracheostomy tube is pulsing with the heartbeat as the client’s pulse is being taken. No
other abnormal findings are noted. What action by the nurse is most appropriate?
a. Call the operating room to inform them of a pending emergency case.
, b. No action is needed at this time; this is a normal finding in some clients.
c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
d. Stay with the client and have someone else call the primary health care
provider immediately.
ANS: D
This client may have a tracheoinnominate artery fistula, which can be a life-
threatening emergency if the artery is breached and the client begins to hemorrhage.
Since no bleeding is yet present, the nurse stays with the client and asks someone else
to notify the primary health care provider. If the client begins hemorrhaging, the nurse
removes the tracheostomy and applies pressure at the bleeding site. The client will
need to be prepared for surgery.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Tracheostomy, Medical emergencies
MSC: Client Needs Category: Physiological Integrity: Physiological
Adaptation
3. A client with a new tracheostomy is being seen in the oncology clinic. What finding
by the nurse best indicates that goals for the client’s decrease in self-esteem are being
met?
a. The client demonstrates good understanding of stoma care.
b. The client has joined a book club that meets at the library.
c. Family members take turns assisting with stoma care.
d. Skin around the stoma is intact without signs of infection.
ANS: B
The client joining a book club that meets outside the home and requires him or her to
go out in public is the best sign that goals for disrupted self-esteem are being met. The
other findings are all positive signs but do not relate to this client problem.
