A client has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar. Which assessment finding requires immediate action by the nurse?
a. Constant, nonproductive coughing
b. Blood-tinged sputum
c. Rhonchi in upper lobes
d. Dry mucous membranes
A
Causes and manifestations of lung injury from oxygen toxicity include nonproductive cough, substernal chest pain, GI upset, and dyspnea. Blood-tinged sputum is expected in clients with new tracheostomies. Rhonchi in upper lobes indicates sputum that can be expectorated and is not an emergent problem. Dry mucous membranes should be lubricated, and the client's hydration status can be checked.
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