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 C

Explanation

Choice A rationale:

Switching to a simple face mask is not the appropriate intervention for nasal dryness and irritation. A simple face mask covers the nose and mouth, and it may not provide enough relief for nasal dryness as the oxygen flow is still directed towards the nose.

Choice B rationale:

Increasing the flow rate of oxygen will not directly improve humidity. Nasal dryness and irritation are often caused by the lack of moisture in the delivered oxygen. Increasing the flow rate may worsen the issue.

Choice C rationale:

Assessing the patient's nares for patency and skin integrity is the appropriate intervention. Nasal dryness and irritation can be caused by inadequate humidification of the oxygen. Checking the patency of the nares and the condition of the skin can help identify any issues that may be contributing to the discomfort.

Choice D rationale:

Reassuring the patient that nasal dryness is a normal side effect is not sufficient. While nasal dryness can be a common side effect of using a nasal cannula, it is essential to address the issue and provide appropriate interventions to alleviate the discomfort and prevent complications.

A. PaO2 80 mmHg. B. SaO2 88%. C. RR 32/min. D. BP 160/90 mmHg.

Correct Answer is A

Explanation

The correct answer is choice a. PaO2 80 mmHg.

Choice A rationale:

PaO2 (partial pressure of oxygen in arterial blood) of 80 mmHg indicates that the oxygen therapy has been effective. Normal PaO2 levels range from 75 to 100 mmHg, so a value of 80 mmHg suggests adequate oxygenation.

Choice B rationale:

SaO2 (arterial oxygen saturation) of 88% is below the normal range (typically 95-100%) and indicates hypoxemia, suggesting that the oxygen therapy has not been fully effective.

Choice C rationale:

A respiratory rate (RR) of 32 breaths per minute is significantly higher than the normal range (12-20 breaths per minute) and indicates respiratory distress, suggesting that the oxygen therapy has not been effective.

Choice D rationale:

Blood pressure (BP) of 160/90 mmHg is elevated and indicates hypertension, which is not a direct measure of the effectiveness of oxygen therapy. This finding does not provide information about the patient’s oxygenation status.

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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 assessing a patient who has been using a nasal cannula for oxygen therapy. The patient complains of nasal dryness and irritation. What intervention should the nurse implement?

Correct Answer is C

Explanation

A nurse is caring for a client who has been receiving oxygen via simple face mask for 6 hours. Which of the following assessment findings indicates that oxygen therapy has been effective?

Correct Answer is A

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?

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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?

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