Author Question: A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face ... (Read 79 times)

audie · **on:** Jun 25, 2018

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy and the eyelids are swollen. What action by the nurse takes priority?

a. Assess the client's oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest.

Question 2

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?

a. Administer prescribed anxiolytic medication.
b. Ensure informed consent is on the chart.
c. Reinforce any teaching done previously.
d. Start the preoperative antibiotic infusion.

Loise Hard · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the client's 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.

Answer to Question 2

ANS: B
Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.