A nurse is assessing a client who has a tracheostomy. The nurse ...

[nenivikky]

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]

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.