Author Question: The nurse has just initiated oxygen by nasal cannula for a client with the medical diagnosis of ... (Read 52 times)

saraeharris · **on:** Jul 23, 2018

The nurse has just initiated oxygen by nasal cannula for a client with the medical diagnosis of chronic obstructive pulmonary disease. What is the nurse's next action?

1. Fill the humidifier with normal saline.
2. Pad the tubing where it contacts the client's ears.
3. Set the oxygen delivery to 5 liters.
4. Secure the cannula with ties around the client's head.

Question 2

The nurse who is performing care for a client with a new tracheostomy needs to change the ties. What is the best method for changing these ties?

1. Remove the old ties, clean the area well, and then put on new ties.
2. Attach the new tape and tie with a square knot behind the client's neck.
3. Have an assistant hold the tracheostomy tube in place, remove the soiled ties, and replace the ties.
4. Remove the outer cannula, replace the soiled ties, and reinsert.

Tonny · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 2
Rationale 1: The humidifier should be filled with water prior to initiating therapy.
Rationale 2: It is necessary to pad the cannula where it contacts the client's ears as pressure irritation may occur.
Rationale 3: Since this client has chronic obstructive pulmonary disease, the oxygen should be set at a lower delivery rate (generally no more than 1.5 to 2 Lpm).
Rationale 4: The cannula does not require ties to secure.

Answer to Question 2

Correct Answer: 3
Rationale 1: Removing the ties without an assistant could allow the tracheostomy tube to become dislodged.
Rationale 2: The knot for securing the tracheostomy tube should be tied at the side of the neck to prevent an area of pressure development.
Rationale 3: Since these ties are very soiled, it is likely that they must be removed before new ties are attached. The safest way to perform this intervention is to have an assistant hold the tracheostomy tube flange in place while the nurse removes the old ties and replaces them.
Rationale 4: The outer cannula is not removed in a new tracheostomy.