ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 28 Questions
Question 1 of 5
A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?
Correct Answer: B
Rationale: Room air is 21% oxygen.
Question 2 of 5
A client is scheduled to have a tracheostomy
Correct Answer: B
Rationale: Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytic and antibiotics and reinforcing teaching may also be required but do not take priority.
Question 3 of 5
A client has a tracheostomy that is 2 days old. Upon assessment, the nurse note the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority?
Correct Answer: A
Rationale: This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.
Question 4 of 5
A client has a tracheostomy tube in place. The nurse is monitoring for complications associated with the tracheostomy and notes that it takes increased pressure to maintain a seal with the tracheostomy tube cuff. What action by the nurse is most appropriate?
Correct Answer: B
Rationale: Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This may be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not correct this situation.
Question 5 of 5
An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?
Correct Answer: A
Rationale: The priority is to check the clients oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP does not necessarily need to be reported, and addressing that issue is not the immediate priority.