Coursepoint: Tracheostomy Care

The nurse is preparing to suction a client who has a tracheostomy after cardiac surgery. To help minimize the client's anxiety, which statement made by the nurse is most therapeutic?

"If you experience any difficulty, squeeze my hand and I will stop to allow you to rest a bit."

Place in order, from first to last, the actions the nurse will perform when preparing to suction an alert client via tracheostomy using an open system. Use all options.

1)Explain the procedure to the client. 2)Adjust the bed and position the client. 3)Adjust the wall suction to the appropriate level. 4)Open sterile packages and set up sterile field. 5)Don sterile gloves. 6)Auscultate the client's lung sounds for evaluation of the intervention.

The nurse is suctioning a client with a tracheostomy using an open system device. Which action will the nurse implement specifically to help prevent trauma to the tracheal tissue?

Apply suction at 110 to 130 mm Hg from the wall unit.

A nurse is preparing to suction a client using an open system endotracheal tube. After removing the ventilator tubing from the endotracheal tube, what would the nurse do next?

Attach the manual resuscitation bag to the endotracheal tube to hyperventilate the client.

The nurse has just completed open system endotracheal suctioning on a client. The client now has decreased oxygen saturation readings. Which actions should the nurse take? Select all that apply.

Auscultate lung sounds., Remain with the client., Hyperoxygenate the client.

A nurse is preparing to suction a client using a closed system endotracheal tube (ET) already in place. After inserting the saline dosette (or syringe) into the port, what would the nurse do next?

Hyperventilate the client using the sigh button on the ventilator.

The nurse has assessed a client with a tracheostomy and decided that suctioning is needed. Which action will the nurse implement to help prevent complications?

Limit suctioning passes to no more than three per episode.

A nurse is preparing to retape a client's endotracheal tube. What should the nurse do? Select all that apply.

Measure the client's oxygen saturation level., Verify the endotracheal tube length., Assess the client's lung sounds., Provide pain medication to the client.

A nurse is securing the endotracheal tube of a client who is unconscious. Which guideline should the nurse follow while carrying out this procedure?

Obtain the assistance of a second person.

The nurse is providing tracheostomy care for a client and cleans the nondisposable inner cannula with the brush. What should the nurse do next?

Place the inner cannula in a basin of sterile saline.

The intensive care nurse is caring for a client requiring frequent endotracheal suctioning while on a mechanical ventilator. During the suctioning process, the client is unintentionally extubated. What should the nurse do? Select all that apply.

Remain with the client., Assess the client's vital signs., Notify the health care provider.

The nurse is assessing a client with an endotracheal tube and has found some loose and soiled tape on the client's face. What is the best action by the nurse?

Request another nurse to assist with the retaping of the endotracheal tube.

The nurse is suctioning a client on a mechanical ventilator using a closed system endotracheal tube. In the process of advancing the catheter, the nurse meets resistance. What should the nurse do?

Withdraw the catheter at least 0.5 in (1.25 cm) before applying suction

While suctioning a client, the nurse inserts a closed-system suction catheter into the tracheostomy tube and meets resistance. Which action should the nurse take?

Withdraw the catheter at least 0.5 in (1.25 cm) before applying suction.

The nurse is inserting the suction catheter into a client's tracheostomy and suddenly meets resistance. Which action would be most appropriate?

Withdraw the catheter at least 0.5 in (1.25 cm).

When providing tracheostomy care to a client with a disposable inner cannula, at which point would the nurse put on sterile gloves?

after removing the old inner cannula

Which client is most likely to need administration of pain medication before being suctioned via the tracheostomy?

client who had abdominal surgery

The nurse is suctioning a client's tracheostomy using an open system. For which action should the nurse use the gloved, dominant hand?

manipulating the suction catheter

After changing a client's tracheostomy holder, the nurse determines that the collar fits properly when:

the client can flex the neck comfortably.

Place in order, from first to last, the actions the nurse will perform when suctioning a client using a closed system suction. Use all options.

1)Explain the procedure to the client. 2)Turn on the suction at the wall unit. 3)Grasp the suction catheter through the protective sheath. 4)Withdraw the catheter while applying intermittent suction. 5)Assess the client's respiratory status for improvement.

The nurse is caring for a client whose respirations are supported by a ventilator. The nurse is preparing to suction the client's endotracheal tube using a closed suctioning system. Place the following steps in the correct order. Use all options.

1)Hyperventilate the client. 2)Turn the catheter safety cap to enable the suction button. 3)Grasp the catheter and advance it to the predetermined length. 4)Depress the suction button to apply intermittent suction. 5)Clear secretions from the sheath. 6)Turn the catheter safety cap to disable the suction button.

The nurse is changing a disposable inner cannula on a tracheostomy client, Place in order, from first to last, the actions the nurse will perform. Use all options.

1)Open supplies using aseptic technique. 2)Remove oxygen source to tracheostomy if present. 3)Use nondominant hand to stabilize the outer cannula and faceplate. 4)Remove inner cannula and site dressing and place them in disposable bag. 5)Remove and discard clean gloves, and put on sterile gloves. 6)Use dominant hand to pick up the new inner cannula, and insert it into the outer cannula.

After assessing clients with a tracheostomy, which client will the nurse suction?

A client with rhonchi in upper airways noted on auscultation.

The nurse is preparing to provide tracheostomy care to a client with a new tracheostomy. Which action should the nurse take before beginning the procedure?

Assess the client for pain and administer analgesic as needed.

The nurse has just finished suctioning a client with a tracheostomy. Which action should the nurse take next?

Assess the client's lung sounds.

The nurse is preparing to perform suctioning using an open system endotracheal tube. What should the nurse do prior to suctioning the client? Select all that apply.

Confirm the suction prescription in the client's medical record., Assess the client's level of pain and medicate, if needed., Determine the need for endotracheal suctioning.

A nurse is caring for an adult client with an endotracheal tube. The nurse recognizes that retaping of the tube is required and prepares the tape. Which actions should the nurse take at this time? Select all that apply.

Cut a piece of tape long enough to reach from one jaw, around the back of neck, to the other jaw., Measure a piece of tape to reach from the client's neck to the mouth, and then add 20 cm.

After changing the disposable inner cannula and changing the dressing of a client who has a tracheostomy, a nurse prepares to change the client's tracheostomy collar. Which action would the nurse take first?

Enlist the assistance of a second nurse.

The nurse is providing tracheostomy care to a client and is preparing to change the client's tracheostomy collar. Which action would be most appropriate?

Enlist the help of a second nurse to hold the tracheostomy tube in place while the old collar is removed and the new collar is placed.

The nurse has just finished replacing a disposable inner cannula of a client's tracheostomy. The client begins coughing and dislodges the tracheostomy. Which action should the nurse take first?

Insert the obturator into a new tracheostomy and insert the tracheostomy into the stoma.

When suctioning a client with a tracheostomy using an open system, which actions by the nurse would help to prevent hypoxemia during the procedure? Select all that apply.

Limit suctioning to 10 to 15 seconds each time., Pause for 30 to 60 seconds between suctioning attempts., Hyperventilate the client with 3 to 6 breaths before suctioning.

On assessment, the nurse notes significant secretions on the client's tracheostomy dressing. The health care provider's prescription states that tracheostomy site care is to be done once per shift. The nurse has already performed site care once during the current shift. What is the best action by the nurse?

Perform site care again and document the procedure.

The nurse if providing tracheostomy care to a client with a nondisposable inner cannula. Which action should the nurse take next after removing the inner cannula?

Replace the client's oxygen source over the outer cannula.

On assessment, the nurse notes that the tracheostomy ties are grossly soiled and require changing. No one is available to assist at this time. What is the best action by the nurse?

Secure the new tracheostomy ties before removing the old ties.

The nurse is preparing to perform suctioning using a closed system endotracheal tube for a client who is on a mechanical ventilator. What should the nurse do first?

Set the suction to the appropriate pressure.

When suctioning the tracheostomy, when would the nurse suction the oral cavity?

Shortly after suctioning the tracheostomy.

The nurse is providing site care for a client with a tracheostomy using a nondisposable inner cannula. Which step is recommended to release the lock on the device?

Stabilize the outer cannula and faceplate with the nondominant hand

While providing care to a client who has a tracheostomy with a nondisposable inner cannula, the nurse observes secretions that have accumulated in the outer cannula. Which action would the nurse take?

Suction the outer cannula using strict aseptic technique

The nurse is observing a family caregiver doing a return demonstration of tracheostomy care for a client with a nondisposable inner cannula. Which action by the family caregiver indicates that additional teaching is required?

The family caregiver rotates the inner cannula clockwise with the nondominant hand to release the lock.

The nurse is preparing an educational inservice about endotracheal suctioning using an open suctioning system. Which concept should the nurse plan to include?

The suction catheter should be inserted to a predetermined length—no more than 1 cm past the end of the endotracheal tube.

The nurse is providing tracheostomy care for a client. When changing the dressing, which action would be most appropriate for cleaning the stoma?

Use each applicator only once, moving from the stoma site outward.

The nurse is preparing to provide tracheostomy care to a client. The client's tracheostomy dressing is soiled, but a commercially prepared tracheostomy dressing is not available. Which action should the nurse perform?

Use two folded gauze sponges on each side of the stoma.

An intensive care nurse is receiving a female client from the emergency room. The client suffered head and facial trauma during a motor vehicle accident and requires an endotracheal tube and mechanical ventilation. What supplies should the nurse anticipate needing at the bedside? Select all that apply.

a bag-valve mask and suction equipment, an extra endotracheal tube of the same size, commercially prepared endotracheal tube holder

The intensive care nurse is caring for a client requiring frequent endotracheal suctioning using an open system. What equipment should the nurse keep easily accessible at the bedside? Select all that apply.

a bag-valve mask, suction catheters, face shield

The nurse is preparing to suction the tracheostomy of a client. The nurse would place which client in the lateral position, facing the nurse?

unconscious client, after abdominal surgery

The nurse is observing a student nurse suction a client with a tracheostomy using an open system. Which action by the student nurse will require additional instruction by the nurse? The student nurse:

uses a manual resuscitation bag to give the client 2 big breaths before beginning.

When preparing to suction a client's tracheostomy, which action by the nurse best helps to prevent the introduction of microorganisms into the respiratory tract?

using only the dominant hand to handle and manipulate the catheter