Tracheostomy Care & ABGs EAQ (Care of the Patient with Chronic Conditions)

When the nurse is assessing a client after tracheostomy placement, which finding requires immediate action by the nurse? 1. Crackling of the skin on palpation 2. Small amount of blood at the surgical site 3. Client reports the area around incision is tender 4. The client is unable to speak with a cuffed tube

Answer: 1. Crackling of the skin on palpation Explanation: Crackling of the skin on palpation indicates the presence of subcutaneous emphysema, which the nurse will immediately report to the health care provider. A small amount of blood at the surgical site is expected and will be monitored for signs of hemorrhage. Tenderness after the surgical procedure would be expected. Inability of the client to speak with a cuffed tube is expected because airflow prevents use of the vocal cords.

A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client? 1. Encouraging a fluid intake of 3 L daily 2. Suctioning via the tracheostomy every hour 3. Applying an occlusive dressing over the surgical site 4. Using cotton balls to cleanse the stoma with peroxide

Answer: 1. Encouraging a fluid intake of 3 L daily Explanation: Increased fluids help liquefy secretions, enabling the client to clear the respiratory tract by coughing. Suctioning frequently will irritate the mucosal lining of the respiratory tract, which can result in more secretions. An occlusive dressing will block air exchange; the tracheostomy is now the client's airway. The use of cotton balls around a tracheostomy introduces the risk of aspiration of one of the cotton fibers; gauze should be used.

A client develops subcutaneous emphysema after the surgical creation of a tracheostomy. Which assessment by the nurse most readily detects this complication? 1. Palpating the neck or face 2. Evaluating the blood gases 3. Auscultating the lung fields 4. Reviewing the chest x-ray film

Answer: 1. Palpating the neck or face Explanation: Subcutaneous emphysema refers to the presence of air in the tissue that surrounds an opening in the normally closed respiratory tract; the tissue appears puffy, and a crackling sensation is detected when trapped air is compressed between the nurse's palpating fingertips and the client's tissue. Gas exchange and thus blood gases are not affected. The lungs are not affected.

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning? 1. Preoxygenate the client before suctioning. 2. Employ gentle suctioning as the catheter is being inserted. 3. Loosen the client's secretions before suctioning by instilling saline. 4. Ensure that the cuff of the tracheostomy is inflated during suctioning

Answer: 1. Preoxygenate the client before suctioning. Explanation: Administration of 100% oxygen for a few minutes before suctioning reduces the risk of hypoxia, the major complication of suctioning. Suction is applied as the catheter is withdrawn, not during insertion, to prevent hypoxia. Tracheostomy cuffs are indicated when the client is on mechanical ventilation. Although a saline solution may be instilled into a tracheostomy, this practice is not recommended.

The nurse is suctioning a client's airway. Which nursing action will limit hypoxia? 1. Limit suctioning with catheter to 30 seconds. 2. Apply suction only after the catheter is inserted. 3. Lubricate the catheter with saline before insertion. 4. Use a sterile suction catheter for each suctioning episode.

Answer: 2. Apply suction only after the catheter is inserted. Explanation: The negative pressure from suctioning removes oxygen and secretions; suction should be applied only after the catheter is inserted and is being withdrawn. Limiting suctioning with the catheter to half a minute is too long; suctioning should be limited to 10 seconds. Lubrication will facilitate insertion and minimize trauma; it will not prevent hypoxia. The use of a sterile catheter helps prevent infection, not hypoxia.

Which nursing action is appropriate when suctioning the secretions of a client with a tracheostomy? 1. Use a new sterile catheter with each insertion. 2. Initiate suction as the catheter is being withdrawn. 3. Insert the catheter until the cough reflex is stimulated. 4. Remove the inner cannula before inserting the suction catheter.

Answer: 2. Initiate suction as the catheter is being withdrawn. Explanation: During suctioning of a client's secretions, negative pressure (suction) should not be applied until the catheter is ready to be drawn out because, in addition to the removal of secretions, oxygen is being depleted. The sterility of the catheter can be maintained during one suctioning session; a new sterile catheter should be used for each new session of suctioning. A cough reflex may be absent or diminished in some clients; the catheter should be inserted approximately 12 cm (4-5 inches) or just past the end of the tracheostomy tube. The inner cannula is not removed during suctioning; it may be removed during tracheostomy care.

A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason that suctioning is included in the client's plan of care? 1. Humidified oxygen is saturated with fluid. 2. The tracheostomy tube interferes with effective coughing. 3. The inner cannula of the tracheostomy tube irritates the mucosa. 4. The weaning process increases the amount of respiratory secretions.

Answer: 2. The tracheostomy tube interferes with effective coughing. Explanation: Because the tracheostomy tube enters the trachea below the glottis, the client is unable to close the glottis to retain air in the lungs; this prevents an increase in the intrathoracic pressure and the ability to open the glottis to expel an explosive cough. Humidified oxygen decreases the need for suctioning because it liquefies secretions, which then are easier to expel. The outer, not inner, cannula of a tracheostomy tube irritates the mucosa. Weaning begins when the respiratory status improves and the amount of respiratory secretions subsides.

Which actions will the nurse include when doing tracheostomy care? Select all that apply. One, some, or all responses may be correct 1. Suction the client before starting tracheostomy care. 2. Use sterile technique when cleaning the inner cannula. 3. Use sterile cotton-tipped swabs to clean the inner cannula. 4. Don sterile gloves before removing the inner cannula. 5. Use hydrogen peroxide to clean the skin around the stoma.

Answer: 2. Use sterile technique when cleaning the inner cannula. (Correct) 4. Don sterile gloves before removing the inner cannula. (Correct) Explanation: Sterile technique is used when cleaning the inner cannula to avoid transmitting microorganisms to the lungs. Sterile gloves are worn when removing the inner cannula. There is no need to suction the client before starting tracheostomy care, although the client may be pre-oxygenated before removing the inner cannula. A brush is used to clean the inner cannula. Hydrogen peroxide is used to clean secretions from the inner cannula, the cannula is rinsed with normal saline. Because hydrogen peroxide can be irritating to tissue, normal saline is used to clean the skin around the tracheostomy stoma.

When the nurse is reviewing a client's arterial blood gas results, which finding is consistent with respiratory alkalosis? 1. An elevated pH, elevated partial pressure of carbon dioxide (PCO2) 2. A decreased pH, elevated PCO2 3. An elevated pH, decreased PCO2 4. A decreased pH, decreased PCO2

Answer: 3. An elevated pH, decreased PCO2 Explanation: In respiratory alkalosis the pH level is elevated because of loss of hydrogen ions; the PCO2 level is low because carbon dioxide is lost through hyperventilation. An elevated pH and elevated PCO2 are partially compensated metabolic alkalosis. A decreased pH and elevated PCO2 are respiratory acidosis. A decreased pH and decreased PCO2 are metabolic acidosis with some compensation.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The client's arterial blood gases deteriorate, and respiratory failure is impending. Which clinical indicator is consistent with the client's condition? 1. Cyanosis 2. Bradycardia 3. Mental confusion 4. Distended neck veins

Answer: 3. Mental confusion Explanation: Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).

The nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89 mm Hg, PCO2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? 1. Respiratory alkalosis 2. Poor oxygen perfusion 3. Normal acid-base balance 4. Compensated metabolic acidosis

Answer: 3. Normal acid-base balance Explanation: All data are within expected limits; PO2 is 80 to 100 mm Hg, PCO2 is 35 to 45 mm Hg, and the pH is 7.35 to 7.45. None of the data are indicators of fluid balance, but of acid-base balance. Oxygen (PO2) is within the expected limits of 80 to 100 mm Hg. With respiratory alkalosis, the blood pH is greater than 7.45 and the PCO2 is greatly decreased. With metabolic acidosis, the pH is less than 7.35.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco2 of 60 mm Hg. These blood gas results require nursing attention because they indicate which condition? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

Answer: 3. Respiratory acidosis Explanation: The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO2, and the acceptable range of arterial Pco2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis.

The nurse instructs a client to breathe deeply to open collapsed alveoli. Which explanation could the nurse offer to explain the relationship between alveoli and improved oxygenation? 1. The alveoli need oxygen to live. 2. The alveoli have no direct effect on oxygenation. 3. Collapsed alveoli increase oxygen demand. 4. Oxygen is exchanged for carbon dioxide in the alveolar membrane.

Answer: 4. Oxygen is exchanged for carbon dioxide in the alveolar membrane. Explanation: The exchange of oxygen and carbon dioxide occurs in the alveolar membrane. If the alveoli collapse, this exchange cannot occur because pulmonary ventilation is reduced. Explaining this process in simple terms to a client may increase compliance with recommended breathing exercises aimed at improving oxygenation. Alveoli do have a direct effect on oxygenation. The statements that alveoli need oxygen to live and that collapsed alveoli increase oxygen demand are nonspecific regarding the pathophysiology of the alveolar membrane.

Which action will the nurse take to support safe oral intake after a tracheostomy? 1. Include thin liquids. 2. Provide large meals. 3. Inflate the tracheostomy cuff fully. 4. Position client as upright as possible.

Answer: 4. Position client as upright as possible. Explanation: After tracheostomy, positioning the client as upright as possible supports safe eating by preventing aspiration. Thin liquids are more difficult to swallow and increase the risk for aspiration. Large meals may cause overdistention of the stomach and lead to regurgitation and aspiration; meals should be small and frequent. The tracheostomy cuff should be deflated to decrease interference with swallowing.

The nurse is caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. The plan of care for the tube would include which nursing intervention? 1. Verify that an inner cannula is in place. 2. Change the tracheostomy tube every week. 3. Clean the tracheostomy once a day. 4. Verify that a low-pressure cuff is in place.

Answer: 4. Verify that a low-pressure cuff is in place. Explanation: A low-pressure cuff permits tidal volume to reach the lungs while preventing tracheal necrosis. The tracheostomy tube can be a single-lumen tube or can have inner and outer cannulas. A tracheostomy tube does not have to be changed weekly. The tracheostomy should be cleaned every 8 hours and whenever necessary.

The nurse is caring for a client whose mechanical ventilator settings include the use of positive end-expiratory pressure (PEEP). This treatment improves oxygenation primarily through which mechanism of action? 1. Providing more oxygen to lung tissue 2. Forcing pressure into lung tissue, which improves gas exchange 3. Opening collapsed alveoli and keeping them open 4. Opening collapsed bronchioles, which allows more oxygen to reach lung tissue

3. Opening collapsed alveoli and keeping them open

A client has a tracheostomy tube with a high-volume, low-pressure cuff. The nurse understands that type of cuff is designed to prevent which occurrence? 1. Any leakage of air 2. Lung infection 3. Mucosal necrosis 4. Tracheal secretions

Answer: 3. Mucosal necrosis Explanation: These cuffs do not compress the capillary beds and thus do not cause tracheal damage. A minimal air leak is desirable to ensure the lowest possible pressure in the cuff while still maintaining placement of the tube. Surgical asepsis, not the use of these cuffs, prevents infection. Secretions are increased because the cuff is a foreign body in the trachea.

Which finding in a client who has home oxygen therapy with a tracheostomy collar requires immediate action by the home health nurse? 1. Condensation in the tubing 2. Oxygen flow rate 9 L/min 3. Low fluid level in the humidifier 4. Scented candle burning in the room

Answer: 4. Scented candle burning in the room Explanation: Oxygen itself is not combustible, but it supports combustion and fire can spread quickly in the presence of oxygen. The nurse will immediately put out the candle and reeducate the client and caregivers about the need to avoid any flame when oxygen is being used. Condensation in the tubing should be emptied but does not present an immediate danger to the client. Oxygen flow rate for tracheostomy collars should be at least 10 L/min and the oxygen flow may need to be increased, but the higher priority would be to decrease fire risk. Water should be added to the humidifier, but this can be done after putting out the candle to decrease risk for fire.

The nurse is suctioning a client's tracheostomy. What is the correct order of nursing actions when performing this procedure? 4. Don sterile gloves. 5. Guide the catheter into the tracheostomy tube using a sterile-gloved hand. 2. Prepare by turning suction on to between 80 and 120 mm Hg pressure. 3. Hyperoxygenate using 100% oxygen. 1. Auscultate the lungs and check the heart rate.

Answer: 1. Auscultate the lungs and check the heart rate. 2. Prepare by turning suction on to between 80 and 120 mm Hg pressure. 3. Hyperoxygenate using 100% oxygen. 4. Don sterile gloves. 5. Guide the catheter into the tracheostomy tube using a sterile-gloved hand. Explanation: The status of the client should be ascertained as a baseline before starting the procedure. The suction should be turned on to check its adequacy before beginning. Because oxygen will be lost during suctioning, the client should be oxygenated using 100% oxygen before initiating the procedure. Then the nurse should don sterile gloves to protect the client from infection and guide the catheter into the tracheostomy tube without using negative pressure.

Assessment findings of a client with smoke inhalation include a negative chest x-ray and arterial blood gases that show a PO 2 of 85 mm Hg, a PCO 2 of 45 mm Hg, and a pH of 7.35. Which interventions would the nurse anticipate will be prescribed? Select all that apply. One, some, or all responses may be correct. 1. Coughing 2. Deep breathing 3. Bronchodilators 4. Humidified oxygen 5. Bronchial suctioning

Answer: 1. Coughing 2. Deep breathing 3. Humidified oxygen Explanation: Coughing moves secretions toward the mouth to be expectorated. Deep breathing expands the alveoli and increases the amount of oxygen being delivered to the alveolar capillary beds. Humidified oxygen increases the amount of oxygen that is being delivered to the alveolar capillary beds. Bronchodilators are not indicated at this time because the x-ray, PCO2, and pH are still within acceptable limits. Bronchial suctioning is not indicated at this time because the x-ray, PCO2, and pH results are still within acceptable limits.