Author Question: A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is ... (Read 131 times)

nenivikky

  • Hero Member
  • *****
  • Posts: 516
A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate?
 
  a. Call the operating room to inform them of a pending emergency case.
  b. No action is needed at this time; this is a normal finding in some clients.
  c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
  d. Stay with the client and have someone else call the provider immediately.

Question 2

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
 
  a. The client demonstrates good understanding of stoma care.
  b. The client has joined a book club that meets at the library.
  c. Family members take turns assisting with stoma care.
  d. Skin around the stoma is intact without signs of infection.


leahm14

  • Sr. Member
  • ****
  • Posts: 322
Answer to Question 1

ANS: D
This client may have a trachea-innominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery.

Answer to Question 2

ANS: B
The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for Impaired Self-Esteem are being met. The other findings are all positive signs but do not relate to this nursing diagnosis.



Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question
 

Did you know?

Your chance of developing a kidney stone is 1 in 10. In recent years, approximately 3.7 million people in the United States were diagnosed with a kidney disease.

Did you know?

Alzheimer's disease affects only about 10% of people older than 65 years of age. Most forms of decreased mental function and dementia are caused by disuse (letting the mind get lazy).

Did you know?

Amphetamine poisoning can cause intravascular coagulation, circulatory collapse, rhabdomyolysis, ischemic colitis, acute psychosis, hyperthermia, respiratory distress syndrome, and pericarditis.

Did you know?

In the United States, there is a birth every 8 seconds, according to the U.S. Census Bureau's Population Clock.

Did you know?

After 5 years of being diagnosed with rheumatoid arthritis, one every three patients will no longer be able to work.

For a complete list of videos, visit our video library