A nurse is planning care for a patient who has a tracheostomy and requires oxygen therapy via tracheostomy collar. Which of the following interventions should the nurse include in the plan of care?
Monitor the patient's respiratory rate, depth, rhythm, and effort.
Educate the patient on how to use and care for the tracheostomy collar.
Implement safety measures to prevent fire hazards from the oxygen source.
All of the above.
The Correct Answer is D
Choice A rationale:
Monitoring the patient's respiratory rate, depth, rhythm, and effort is crucial for assessing the effectiveness of oxygen therapy and ensuring proper oxygenation through the tracheostomy collar.
Choice B rationale:
Educating the patient on how to use and care for the tracheostomy collar is essential to ensure the patient's safety and compliance with the therapy.
Choice C rationale:
Implementing safety measures to prevent fire hazards from the oxygen source is crucial, especially when oxygen is delivered via tracheostomy collar, which may have increased oxygen flow rates.
Choice D rationale:
This is the correct choice. All the provided interventions (monitoring respiratory parameters, patient education, and safety measures) are essential components of the plan of care for a patient with a tracheostomy who requires oxygen therapy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The goal of oxygen therapy is not to provide the highest fraction of inspired oxygen (FiO2) possible. This approach can be harmful because excessively high FiO2 levels can lead to oxygen toxicity and other side effects, especially in patients with certain conditions like chronic obstructive pulmonary disease (COPD).
Choice B rationale:
The goal of oxygen therapy is to use the lowest FiO2 that achieves an acceptable blood oxygen level without harmful side effects. This approach is known as titrating the oxygen therapy to the patient's needs and helps prevent potential complications associated with excessive oxygen administration.
Choice C rationale:
Maintaining a constant FiO2 regardless of the patient's breathing pattern is not the goal of oxygen therapy. In some cases, patients may require varying FiO2 levels based on their respiratory status, so it is essential to adjust the oxygen delivery accordingly.
Choice D rationale:
Delivering a fixed amount of oxygen that is independent of the patient's condition is not the goal of oxygen therapy. Oxygen therapy should be individualized and tailored to the patient's specific needs to optimize its effectiveness and safety.
Correct Answer is A
Explanation
A humidifier.
Choice A rationale:
A humidifier is necessary to prevent complications in a patient receiving oxygen therapy via a tracheostomy collar. Oxygen delivered through a tracheostomy can dry out the airways and cause discomfort and potential complications. Adding humidity helps maintain airway moisture and prevents drying of the mucous membranes, reducing the risk of mucus plugs and irritation.
Choice B rationale:
A water seal is not necessary for a patient receiving oxygen therapy via a tracheostomy collar. Water seals are used in chest drainage systems to prevent air from entering the pleural space, but they are not relevant in this scenario.
Choice C rationale:
A suction catheter is used to clear secretions from the airway but is not directly related to preventing complications with oxygen therapy via a tracheostomy collar.
Choice D rationale:
A chest tube is not needed for a patient receiving oxygen therapy via a tracheostomy collar. Chest tubes are inserted to drain fluid or air from the pleural space, which is not applicable to this situation.
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