The nurse is caring for a client with a tracheostomy receiving oxygen therapy. Which intervention should the nurse prioritize to prevent infection and ensure proper oxygen delivery?
Regularly suctioning the tracheostomy tube.
Assessing the client's respiratory rate every hour.
Applying a sterile dressing over the tracheostomy site.
Administering humidified oxygen through the tracheostomy tube.
The Correct Answer is C
Answer: c. Applying a sterile dressing over the tracheostomy site.
Explanation: Applying a sterile dressing over the tracheostomy site helps prevent infection by providing a barrier against microorganisms. It also ensures a clean environment for optimal oxygen delivery and promotes wound healing.
Incorrect choices: a. Regularly suctioning the tracheostomy tube is important for maintaining airway patency but may not directly address infection prevention or oxygen delivery.
b. Assessing the client's respiratory rate every hour is important for monitoring respiratory status but does not specifically address infection prevention or oxygen delivery.
d. Administering humidified oxygen through the tracheostomy tube may be necessary to provide moistened air to the client's lungs but does not directly address infection prevention.
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Related Questions
Correct Answer is B
Explanation
Answer: b. Disconnect the tubing and drain the condensation.
Explanation: Condensation in the oxygen tubing can impede the flow of oxygen and reduce the effectiveness of oxygen therapy. The nurse should disconnect the tubing and drain the condensation before reconnecting and continuing oxygen therapy.
Incorrect choices: a. Increasing the oxygen flow rate does not address the issue of condensation and may lead to unnecessary oxygen supplementation.
c. Replacing the oxygen tubing with a new one immediately may not be necessary if the condensation can be resolved by draining it.
d. Placing a heat-moisture exchanger (HME) on the oxygen tubing is not necessary for managing condensation but can be used to provide humidification for clients receiving high-flow oxygen therapy.
Correct Answer is D
Explanation
Answer: d. Loose fit of the mask on the client's face.
Explanation: A loose fit of the mask on the client's face can result in a significant reduction in the delivery of high-flow oxygen therapy. It is essential to ensure a proper seal and fit of the mask to maximize the effectiveness of oxygen therapy. Immediate intervention is needed to readjust and secure the mask properly.
Incorrect choices: a. An oxygen flow rate of 10 L/min may be appropriate for high-flow oxygen therapy, depending on the client's condition and prescribed treatment.
b. An oxygen saturation of 95% indicates adequate oxygenation and is within the target range for most clients.
c. Condensation in the mask can be managed by draining it appropriately and does not necessarily require immediate intervention unless it significantly obstructs oxygen flow.
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