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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A rationale:

Increasing the flow rate of oxygen may not be the priority action because the patient's shortness of breath could be due to a problem with the mask itself, rather than the amount of oxygen being delivered. Before making any adjustments to the oxygen flow rate, it is essential to assess the equipment's integrity.

Choice B rationale:

This is the priority action because a partial rebreather mask relies on the patient's exhaled breath to partially fill the reservoir bag. If the mask bag does not remain inflated during both inspiration and expiration, the patient may not be receiving the appropriate oxygen concentration, leading to increased shortness of breath. Checking the mask bag ensures that the mask is functioning correctly and delivering the intended oxygen concentration.

Choice C rationale:

Switching the patient to a non-rebreather mask for higher oxygen delivery is not the priority action in this scenario. The non-rebreather mask is used when high oxygen concentrations are required, such as in emergencies or when a patient's condition requires immediate intervention. However, the priority at this moment is to assess the current equipment's effectiveness before considering a change in oxygen delivery method.

Choice D rationale:

Reassuring the patient that shortness of breath is common with this type of mask is not appropriate without first addressing the issue at hand. The nurse should first assess the mask's functionality to ensure it is working correctly and providing the appropriate oxygen concentration before addressing the patient's concerns.

A. "You should refill the tank when it feels light and empty.”. B. "You should refill the tank when the pressure gauge reads below 500 psi.”. C. "You should refill the tank when you hear a hissing sound from the valve.”. D. "You should refill the tank when an alarm sounds from the regulator.".

Correct Answer is B

Explanation

Choice A rationale:

Refilling the oxygen tank based on the client's perception of it feeling light and empty is not a reliable method, as it may lead to running out of oxygen unexpectedly.

Choice B rationale:

The nurse should instruct the client to refill the oxygen tank when the pressure gauge reads below 500 psi. This is a standardized method to ensure the client does not run out of oxygen, as the pressure gauge provides an accurate measure of the remaining oxygen in the tank.

Choice C rationale:

Refilling the tank when a hissing sound is heard from the valve is not a valid method for determining the need for a refill and may result in running out of oxygen.

Choice D rationale:

Waiting for an alarm sound from the regulator to refill the tank is not recommended, as the tank could run out of oxygen before the alarm activates.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is using a partial rebreather mask for oxygen therapy. The patient reports feeling short of breath. What is the nurse's priority action?

Correct Answer is B

Explanation

A nurse is teaching a client who is going home on continuous liquid oxygen therapy. The client asks the nurse, "How do I know when to refill the oxygen tank?”. Which of the following responses should the nurse give?

Correct Answer is B

Explanation

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