A nurse is reinforcing teaching with a newly licensed nurse about tracheostomy care for a toddler. Which of the following instructions should the nurse include in the teaching?

Secure the tracheostomy ties so that fingers cannot fit between the ties and the neck.

Suction for 20 seconds.

Clean secretions from the tube using hydrogen peroxide.

Set the vacuum pressure at 120 mmHg for suctioning.

Answer and Explanation

The Correct Answer is D

A) Secure the tracheostomy ties so that fingers cannot fit between the ties and the neck. The ties should be secure but loose enough to fit one finger between the ties and the neck to prevent skin breakdown and maintain comfort.
B) Suction for 20 seconds. Suctioning for 20 seconds is too long and may cause hypoxia. Suction should not exceed 5 to 10 seconds.
C) Clean secretions from the tube using hydrogen peroxide. Hydrogen peroxide can irritate the delicate tissues and is not recommended. Saline or prescribed cleaning agents are preferred.
D) Set the vacuum pressure at 120 mmHg for suctioning. For a toddler, suction pressure should typically be between 80 and 120 mmHg to prevent mucosal damage.

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Correct Answer is D

Explanation

A) "It delivers a specific concentration of oxygen constantly." A nasal cannula does not provide a constant or precise concentration of oxygen, as it is influenced by the client's breathing pattern.
B) "It allows you to remove it for a while when it gets uncomfortable." Removing the nasal cannula intermittently may disrupt oxygen therapy and decrease oxygen saturation.
C) "It delivers the highest concentration of oxygen possible." A nasal cannula delivers low-flow oxygen and does not provide the highest possible oxygen concentration.
D) "It delivers the low concentration of oxygen you need." A nasal cannula is designed for clients who need a low concentration of oxygen, typically between 1 to 6 liters per minute.

A. "Repeat your breathing exercise every 2 hrs." B. "Inhale through your mouth." C. "Hold your breath for 5 seconds." D. "Exhale through your nose."

Correct Answer is C

Explanation

A) "Repeat your breathing exercise every 2 hrs." Repeating breathing exercises should be done a couple of times every hour to help prevent postoperative complications such as atelectasis and pneumonia.
B) "Inhale through your mouth." Clients should inhale through their nose to filter, warm, and humidify the air.
C) "Hold your breath for 5 seconds." Holding the breath for 5 seconds allows for better lung expansion and optimal oxygen exchange.
D) "Exhale through your nose." Clients are generally advised to exhale through pursed lips to create positive airway pressure and prevent airway collapse.

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A nurse is reinforcing teaching with a newly licensed nurse about tracheostomy care for a toddler. Which of the following instructions should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

A client is receiving oxygen therapy via a nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, which of the following explanations about the cannula should the nurse give him?

Correct Answer is D

Explanation

A nurse is reinforcing preoperative teaching for a client about coughing and deep breathing. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

The nurse recognizes that, immediately before a tracheostomy cuff deflation, the patient should:

The nurse clarifies that the condition in which there is a decreased amount of oxygen in the blood is:

A nurse is nasopharyngeal suctioning an adult patient to remove thick secretions. The nurse will:

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?

A nurse is assisting with the care of a client who has a newly inserted chest tube. Which of the following actions should the nurse take?

A patient who will begin oxygen therapy has a history of sinus disorders. This patient would benefit most from which oxygen setup?

A nurse is preparing to suction the airway of a client who has a tracheostomy. Identify the sequence of actions the nurse should take after performing hand hygiene. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

The multiple causes for hypoxia include: (Select all that apply.)