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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
The correct answers are choices A, C, and E.
Choice A rationale:
A Venturi mask is designed to deliver a precise concentration of oxygen and is often used in COPD, where it is important not to over-oxygenate the patient. It allows for the adjustment of oxygen concentration by changing the color-coded entrainment adapters.
Choice B rationale:
A non-rebreather mask is not typically used for clients who require a precise concentration of oxygen because it is designed to deliver high concentrations of oxygen, but without a way to precisely control the amount.
Choice C rationale:
An aerosol mask can be used with a nebulizer system to deliver specific concentrations of oxygen along with medication, which is beneficial for COPD patients who may need bronchodilators or steroids in addition to oxygen therapy.
Choice D rationale:
A simple face mask is not suitable for delivering a precise concentration of oxygen as it does not allow for the fine control needed for COPD patients. It is generally used for short-term oxygen therapy and for patients who require a moderate amount of oxygen.
Choice E rationale:
A tracheostomy collar can provide a specific concentration of oxygen when used with a tracheostomized patient and is suitable for long-term use in COPD patients who have a tracheostomy.
In summary, for a client with COPD who requires a precise concentration of oxygen, the Venturi mask, aerosol mask, and tracheostomy collar are appropriate choices as they allow for the delivery of a specific and controlled amount of oxygen.
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.
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