A nurse is caring for a client receiving oxygen therapy through a transtracheal catheter. What is an important nursing consideration for this client?
Ensuring the catheter is placed in the client's nostrils.
Assessing the client's respiratory rate every 15 minutes.
Monitoring the oxygen flow rate continuously.
Teaching the client proper coughing and deep breathing techniques.
None
None
The Correct Answer is C
c. The nurse should closely monitor the client for signs of oxygen toxicity, such as substernal pain, respiratory distress, and changes in mental status.
Incorrect choices:
a. Ensuring the catheter is placed in the client's nostrils is incorrect as a transtracheal catheter is inserted directly into the trachea, bypassing the nose.
b. Assessing the client's respiratory rate every 15 minutes is too frequent for routine assessment and may disrupt the client's care.
d. While teaching coughing and deep breathing techniques can be important for clients with respiratory issues, it is not the most immediate or critical nursing consideration for clients using a transtracheal catheter.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer: b. Monitoring the client for signs of oxygen toxicity.
Explanation: Oxygen toxicity can occur with prolonged exposure to high levels of oxygen. The nurse should closely monitor the client for signs of oxygen toxicity, such as substernal pain, respiratory distress, and changes in mental status.
Incorrect choices: a. Assessing the client's respiratory rate hourly is a general nursing assessment and not specific to venturi mask therapy.
c. Administering supplemental oxygen as needed is the purpose of providing oxygen therapy and is not a specific consideration for the venturi mask.
d. Ensuring the mask fits tightly over the client's nose and mouth is important for mask effectiveness but is not specific to the venturi mask.
Correct Answer is D
Explanation
Answer: d. Assessing the client for skin breakdown around the mask.
Explanation: When using a face mask for oxygen therapy, the nurse should assess the client's skin for any signs of irritation or breakdown due to prolonged mask use. It is important to ensure proper mask fit and periodically assess the skin integrity to prevent pressure ulcers or skin breakdown.
Incorrect choices:
a. Encouraging the client to remove the mask during meals may compromise oxygen delivery and is not recommended unless otherwise specified by the healthcare provider.
b. Adjusting the mask to cover the client's mouth only may not provide adequate oxygen delivery and is not the correct technique for using a face mask.
c. Checking the client's oxygen saturation every 4 hours is a general nursing assessment and not specific to face mask oxygen therapy. The frequency of oxygen saturation monitoring should be based on the client's condition and healthcare provider's orders.
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