Know what hypoxia is and the signs and symptoms. A nurse is collecting data from a client who has respiratory disorder and displays manifestations of hypoxia. Which of the following findings should the nurse expect?
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Terms in this set (34)
What can happen when a client is being suction? The nurse realizes that suctioning the client may causeHypoxiaKnow the length of insertion for suctioning.The recommended catheter length inserted to suction the adult is1-2 inchesWhat are precautions to take for a patient with a tracheostomy tube? Which of the following precautions must be taken for a patient who has a tracheostomy tube?Keep hemostat at the bedsideKnow the steps of suctioning a patient. The nurse is caring for a client with the tracheostomy tube is preparing to suction. Which of the following nursing actions should the nurse implement before suctioning the client?Give extra oxygenKnow the parts of a tracheostomy tube. A patient diagnosed with throat cancer is 4 days post operative and has a tracheostomy. Which part of the tracheostomy is removed for cleaning?-Inner cannulaWhat is the process that a nurse must perform before doing any perform skills? Before performing any skill, the nurse must first (SATA)Refer to client's medical record, Introduce him/herself, Identify client, Identify clients' allergiesWhat is the priority for a client with a tracheostomy? What is the priority nursing responsibility for the client with a tracheostomy?Maintain a patient airwayKnow the procedure to do when a trach is no longer in place when you find the patient in the room. A nurse is caring for a client following a tracheostomy 2 days ago. The nurse enters the room and notices that the tracheostomy tube is no longer in place. What is the nurse first action?Obtain an obturator and a spare tracheostomy tube from the head of the bed and reinsert, if possibleWhat should you do for a patient who has a trach when communicating? Which of the following interventions should be included when caring for a client with tracheostomy?Provide the client with materials for non-verbal communicationKnow how to prevent hypoxia when suctioning a patient. Which of the following nursing interventions will help prevent hypoxia during suctioning?Hyper-oxygenate patient as ordered by physicianKnow the process and care of a catheter following suctioning. What is the appropriate care of the suction catheter following its use?The catheter must be discarded after each useWhat should you do with an unconscious person when you suction them? Which position is recommended when suctioning the unconscious patient?Side-lyingKnow the types of solution to used when cleaning cannula. Which cleansing solution is appropriate to use when cleansing the inner cannula of the tracheostomy tube?The cleansing solution to be used is hydrogen peroxideKnow the equipment used for a tracheostomy. What equipment should the nurse ensure is available in the patient's room being admitted following a new tracheostomy? (SATA)Pulse oximeter, Spare tracheostomy, Suction catheter kit, Ambu bagKnow when to clean a tracheostomy tube. Which nursing action is most appropriate for the client with a 2 day old tracheostomy?-Clean the tracheostomy tube at least once a shiftKnow when you would use a diagnosis of ineffective airway clearance for a client. The client requires suctioning of pulmonary secretions. An appropriate nursing diagnosis for the client isIneffective airway clearanceKnow how to minimize risk factors for infection in a client with a trach. Which of the following interventions is used to minimize the risk of infections for the client with a tracheostomy? (SATA)Change all respiratory therapy equipment every 8 hours, Remove the water that condenses in the equipment tubing, Provide frequent oral careKnow how to maintain sterile field when opening equipment. When opening the suction catheter, the nurse should leave it in its wrapper and attached to the suction machine toMaintain sterilityKnow the safety of suctioning a patient. The nurse is preparing to suction a client through a tracheostomy tube. Which nursing actions are appropriate and safe for this procedure? (SATA)Moistening the catheter tip in sterile saline solution before suctioning, Preoxygenating the patient before suctioning , Introducing the catheter into the tracheostomy tube using a sterile gloved hand , Assessing the lungs prior to procedureKnow the steps in cleaning the tracheostomy tube. A nurse is preparing to change the neck ties on a tracheostomy tube. To perform a safe procedure, the nurse would plan toHave a second health team member to assistKnow what to look for when suctioning a client. The nurse is suctioning a client. What should the nurse monitor during suctioning?Pulse oximetryMath. The nurse is weighing a client and she weighs 51 kgs. She asks the nurse what is that in pounds. The nurse responds _______ lbs. (FITB) round to the nearest tenth112.44 but they want you to round to the nearest tenth 110Know how to document international times. The client has a medication ordered to be given at 5:30 pm, how would the nurse document that in international time?1730Why would you provide humidified oxygen to a patient with a trach. A nurse is caring for a client who is post operative following a tracheostomy and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this clients' secretions?-Provide humidified oxygen