Exam 2: Tracheostomy & Trach Care (NCLEX)

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy? a. Assess the patient's risk for aspiration. b. Suction the tracheostomy when needed. c. Teach the patient about self-care of the tracheostomy. d. Determine the need for replacement of the tracheostomy tube.

B Suctioning of a stable patient can be delegated to LPNs/LVNs. Patient assessment and patient teaching should be done by the RN.

A patient returns from the OR after having a tracheostomy. While assessing the patient, which observations made by the nurse warrant immediate notification of the provider? A. patient is alert but unable to speak and has difficulty communicating his needs B. small amount of bleeding present at incision C. skin is puffy at the neck area with a crackling sensation D. respirations are audible and noisy with increased RR

C

The nurse assesses a client during suctioning. Which finding indicates that the procedure should be stopped? a. Heart rate increases from 86 to 102 beats/min. b. Respiratory rate increases from 16 to 20 breaths/min. c. Blood pressure increases from 110/70 to 120/80 mm Hg. d. Heart rate decreases from 78 to 40 beats/min.

D A decrease in heart rate indicates that the client is not tolerating the procedure, and the vasovagal reflex may be stimulated. An increase in heart rate may be stimulated by suctioning and is expected, as is a slight increase in blood pressure. A slight increase in respiratory rate after the procedure might be caused by the feeling of oxygen being suctioned from the client's airway, along with secretions.

The nurse assesses a client with a new tracheotomy, and the tracheostomy tube is pulsating in synchrony with the client's heartbeat. Which is the nurse's priority action? a. Notify the health care provider immediately. b. Stabilize the tube by reapplying the ties. c. Change the inner cannula of the tube. d. Increase the inflation pressure of the cuff.

A If a tracheostomy tube is pulsating with the client's heart rate, this could indicate proximity to the innominate artery and may cause erosion of the artery if left in this position. The provider should be notified immediately. Reapplying the ties, changing the inner cannula, and increasing the inflation pressure of the cuff are all interventions that will not solve the immediate problem of proximity of the tube to the innominate artery.

Which interventions help to prevent aspiration during eating for a client with a tracheostomy? (Select all that apply.) a. Provide close supervision for the client during eating and drinking. b. Add liquids to foods to make them thinner and easier to swallow. c. Inflate the tracheostomy cuff tube to maximum pressure before starting. d. Let the client indicate readiness for another bite when being fed. e. Have the client tuck the chin down and forward while swallowing. f. Instruct the client to dry swallow to clear food particles from the throat. g. Place the client in a semi-Fowler's position for an hour after eating.

ADEF The client with a tracheostomy will require close supervision, even if the client is feeding himself or herself. Do not rush the client. Allow him or her to indicate when ready for another bite. Teaching interventions should include instructing the client to tuck the chin down and forward while swallowing to encourage food to move down smoothly. Dry swallowing helps remove food residue. Food may actually become easier to aspirate if it is thinner in texture. The nurse should not initiate adding air to inflate the cuff of a tracheostomy tube further without a physician's order; if possible, the cuff should be deflated during eating. Placing the client in a semi-Fowler's position after the meal will not prevent aspiration.

A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first? A. Auscultate the client's breath sounds while applying a nasal cannula B. Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask C. Apply a 100% non-rebreather mask while administering high-flow oxygen D. Replace the obturator while inserting the tracheostomy tube

B Because a fresh tracheostomy stoma will collapse, the client will lose his airway patency, which will require the nurse to ventilate the client through the mouth and nose while waiting for assistance to re-cannulate the client. Directing someone else to call the Rapid Response Team allows the nurse to provide immediate care required by the client.

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse, if noted by the charge nurse, would cause the charge nurse to intervene? a) The newly hired nurse adjusts the bed to a comfortable working position. b) The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). c) The newly hired nurse explains what she is doing and the reason to the client, even though the client does not appear to be alert. d) The newly hired nurse assesses the client's pain and administers pain medication.

B Care of a tracheostomy tube in a stable situation, such as long-term care and other community-based care settings, may be delegated to licensed practical/vocational nurses (LPN/LVN); not in an acute instance.

A female client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: a. 15 to 60 seconds. b. 5 to 20 minutes. c. 30 to 40 minutes. d. 45 to 60 minutes.

B Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, and then gradually lengthen this interval according to the client's respiratory status. A client who doesn't require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn't be long enough to reveal the client's true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

The client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response? A. "But you know you need this to breathe, right?" B. Do you have a pretty scarf or a large loose collar that you could place over it?" C. "Your family and friends probably won't even care." D. "It won't take you long to learn to manage."

B Suggesting strategies to cover the tracheostomy recognizes client concerns and explores options for dealing with the effects of the procedure.

A family member has been taught to provide oral care to a client with a tracheostomy. Which statement by the family member indicates an accurate understanding of the correct way to provide mouth care? a. "I can use glycerin swabs." b. "I'll use water and a toothette." c. "I can use hydrogen peroxide." d. "It is okay to use mouthwash."

B The best choice for mouth care is water and a toothette because these are the least irritating. Glycerin swabs, hydrogen peroxide, and mouthwash all are too irritating to the mucous membranes of the mouth.

Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? a. Cover stoma with sterile gauze and ventilate through stoma. b. Attempt to reinsert the tracheostomy tube with the obturator in place. c. Assess the patient's oxygen saturation and notify the health care provider. d. Ventilate the patient with a manual bag and face mask until the health care provider arrives.

B The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. Ventilating with a facemask is not appropriate for a patient with a total laryngectomy because there is a complete separation between the upper airway and the trachea.

The nurse is preparing to receive a postoperative client who just had a tracheostomy. Which action by the nurse takes priority? a. Obtain report from the postanesthesia care unit. b. Place a second tracheostomy tube and obturator at the bedside. c. Review orders for postoperative pain medications. d. Order supplies for tracheostomy care for 24 hours.

B The nurse must ensure that a second tracheostomy tube with obturator is available at the bedside in case of accidental decannulation, because tube dislodgment in the first 72 hours is an emergency. Obtaining report and understanding pain medication orders are important for any postoperative client, but for the tracheostomy client, having the extra material on hand is critical. Obtaining supplies for tracheostomy care is not as high a priority as the other three.

A client is being weaned from a tracheostomy tube and has tolerated capping of the tube for 24 hours. Which action by the nurse is most appropriate? a. Collect all materials needed for suturing the stoma shut. b. Place a dry dressing over the stoma and tape it securely. c. Assess the client for air leaking around the tube. d. Select a smaller tracheostomy tube to be inserted.

B The tube will be able to be removed after the client has tolerated capping of it for 24 hours. Therefore, a dry dressing will be able to be placed over the stoma. The stoma will not be sutured. It will heal on its own with a small scar. Airflow should be adequate around the capped tube. The physician will not likely insert the next smallest size tube but instead will remove the existing tube.

A client is being discharged home with a tracheostomy. Which action does the nurse teach the client to decrease the risk for aspiration while eating? a. Swallow quickly. b. Thicken all liquids. c. Rinse all food with water. d. Chew food completely.

B Thickening liquids may assist the client in swallowing and may help prevent aspiration. Swallowing quickly will not decrease the risk of aspiration and may actually put the client at greater risk. It is not recommended that the client drink water to wash down food. Chewing food completely will help prevent choking but will not decrease aspiration risk.

A client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the client cyanotic, with the tracheostomy tube lying on his chest. Which action by the nurse takes priority? a. Auscultate breath sounds bilaterally. b. Ventilate with a resuscitation bag and mask. c. Call a code or the Rapid Response Team. d. Insert a new obturator into the neck.

B Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. First, ventilate the client using a manual resuscitation bag and facemask while another nurse calls for help. Although auscultation of breath sounds is important, the client's airway must be opened and ventilation started. Ventilation should begin while another nurse calls the code. Reinsertion of a fresh tracheostomy tube will require the physician's intervention.

A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take? a. Encourage increased incentive spirometer use. b. Encourage the patient to increase oral fluid intake. c. Put on sterile gloves and use a sterile catheter to suction. d. Preoxygenate the patient for 3 minutes before suctioning.

C This patient needs suctioning now to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. Preoxygenation for 3 minutes is not necessary. Incentive spirometer (IS) use opens alveoli and can induce coughing, which can mobilize secretions. However, the patient with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner.

The nurse observes a nursing student suctioning a client. Which intervention by the student nurse requires the supervising nurse to intervene? a. Checking oxygen saturation post suctioning b. Hyperoxygenating the client after removal of the catheter c. Applying intermittent suction during catheter removal d. Applying suction when the catheter is inserted

D Applying suction as the catheter is introduced allows the tubing to adhere to the airway and destroys cells. The other options are appropriate actions on the part of a nurse or student who is suctioning a client.

While suctioning a client who had a tracheostomy placed 4 days ago, the nurse notes particles of food in the tracheal secretions. Which action by the nurse is most appropriate? a. Increase the inflation pressure in the tracheostomy cuff. b. Add blue dye to a beverage to assess for aspiration. c. Make the client NPO and notify the health care provider. d. Perform a more thorough assessment of the client.

D Before calling the provider, the nurse needs more data, such as lung sounds, presence of cough, pulse oximetry reading, and possibly mental status. The nurse could temporarily make the client NPO while conducting this assessment, but calling the provider must wait until he or she has more complete data. The nurse should not decide to increase the inflation pressure in the tracheostomy cuff on his or her own. Adding dye to food, drink, or tube feeding formulas was commonly done in the past but should be avoided because the dye is toxic to lung tissues if aspirated.

The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction? 1.Suctioning the client every hour 2.Applying suction only during withdrawal of the catheter 3.Hyperventilating the client with 100% oxygen before suctioning 4.Applying suction intermittently during withdrawal of the catheter

1

What would the critical care nurse recognize as a condition that may indicate a patients need to have a tracheostomy? A) A patient has a respiratory rate of 10 breaths per minute. B) A patient requires permanent ventilation. C) A patient exhibits symptoms of dyspnea. D) A patient has respiratory acidosis.

B

A patient with a trach who receives unnecessary suctioning can experience which complications? Select all that apply A. bronchospasm B. mucosal damage C. impaired gag reflex D. bronchodialation E. bleeding

ABE

Which nursing action is important when suctioning the secretions of a client with a tracheostomy? A. use a new sterile catheter with each insertion B. initiate suction as the catheter is being withdrawn C. insert the catheter until the cough reflex is stimulated D. Remove the inner cannula before inserting the suction catheter

B

A patient returns from the OR and the nurses assesses for subcutaneous emphysema, which is a potential complication associated with tracheostomy. How does the nurse assess for this complication? A. checking the volume of the pilot balloon B. listening for airflow through the tube C. inspecting and palpating for air under the skin D. assessing the tube for patency

C

The nurse is caring for a patient with a tracheostomy who has recently been transferred from the ICU. but he has no unusual occurrences related to the tracheostomy or his oxygenation status. What does the routine care for this patient include? A. thorough respiratory assessment at least every 2 hours B. maintaining the cuff pressure between 50 and 100 mm Hg C. Suctioning as needed; maximum suction time of 20 seconds D. changing the tracheostomy dressing once a day

A

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.

When caring for a client with a tracheostomy, the nurse would perform which recommended action? a) Clean the wound around the tube and inner cannula at least every 24 hours. b) Assess a newly inserted tracheostomy every 3 to 4 hours. c) Suction the tracheostomy tube using sterile technique. d) Use gauze dressings over the tracheostomy that are filled with cotton.

C

Which clinical finding in a patient with a recent tracheostomy is the most serious and requires immediate intervention? A. increased cough and difficulty expectorating secretions B. food particles in the tracheal secretions C. pulsating tracheostomy tube in synchrony with the heartbeat D. set tidal volume on the ventilator not being received by the patient

C

A nurse is planning care for a client who is scheduled for a tracheostomy procedure. What equipment should the nurse plan to have at the bedside when the client returns from surgery? 1.Obturator 2.Oral airway 3.Epinephrine (Adrenalin) 4.Tracheostomy set with the next larger size

1

The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted? 1.Rhonchi are auscultated. 2.Pleural friction rub is heard. 3.Fine crackles are auscultated. 4.Pulse oximetry reading is 96%.

1

You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to intervene? A. suctioning the trach tube before performing trach care B. removing old dressings and cleaning off excess secretions C. removing the inner cannula and cleaning using standard precautions D. replacing the inner cannula and cleaning the stoma site

C

The nurse is caring for a patient with a tracheostomy tube. Which action, if performed by the nurse, is incorrect and requires intervention from the charge nurse? 1) The nurse suctions the patient's airway when she hears noisy respirations. 2) The nurse inflates the trach cuff to 30 cm H2O. 3) The nurse ensures that there is an obturator at the patient's bedside. 4) The nurse asks that another nurse help her while she changes the tracheostomy ties for the first time.

2

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? 1.Suctioning is required frequently. 2.The client's skin and mucous membranes are light pink. 3.Aspiration of gastric contents occurs during suctioning. 4.Excessive secretions are suctioned from the tube and stoma.

3

The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem? 1.Fever 2.Epilepsy 3.Hypotension 4.Respiratory failure

3 Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings as a result of impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low.

The nurse is teaching a client about his fenestrated tracheostomy tube. Which statement by the client indicates an accurate understanding of the tube? a. "I'm glad I will still be able to talk with this tube in place." b. "It is great that this tube does not have to be cleaned regularly." c. "This tube will not get dislodged because it never needs suctioning." d. "Because I can't swallow, I will need another tube for eating."

A The client can speak with a fenestrated tube, which has a hole in it and allows air to flow over the vocal cords. The tube still needs to be cleaned and suctioned. The tube may become dislodged, and the client is able to swallow.

A patient was intubated for acute respiratory failure, and there is an endotracheal tube in place. Which nursing interventions are appropriate for this patient? Select all that apply. A. ensure that the oxygen is warmed and humidified B. suction the airway, then the mouth, and give oral care C. Suction the airway with the oral suction equiptment D. Position the tubing so it does not pull on the airway E. apply suction only when withdrawing the suction catheter

ABDE

A patient has a recent tracheostomy. What necessary equipment does the nurse ensure is kept at the bedside? Select all that apply. A. ambu bag B. pair of wire cutters C. oxygen tubing D. suction equipment E. tracheostomy tube with obturator

ACDE

What are possible complications that can occur with suctioning from an artificial airway? Select all that apply A. infection B. coughing C. hypoxia D. tissue (mucosa) trauma E. Vagal stimulation F. bronchospasm

ACDEF

A patient with a trach tube is currently alert and cooperative but seems to be coughing more frequently and producing more secretions than usual. The nurse determines there is a need for suctioning. Which nursing intervention does the nurse use to prevent hypoxia for this patient? A. allow the patient to breathe room air prior to suctioning B. avoid prolonged suctioning time C. suction frequently when the patient is coughing D. use the largest available catheter

B

The nurse is caring for a male client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: a. helping him communicate. b. keeping his airway patent. c. encouraging him to perform activities of daily living. d. preventing him from developing an infection.

B

The nursing student is performing tracheostomy care on a client. Which action by the student leads the supervising nurse to intervene? a. Using folded gauze dressings on both sides of the stoma b. Cutting a slit in a gauze 4 4 pad to fit around the stoma c. Applying new tracheostomy ties before removing old ones d. Tying the twill tape in a square knot on the side of the neck

B Tracheostomy dressings should be made from gauze pads with a manufactured slit in them that fits around the tube. If none are available, use two gauze pads folded in half placed on either side of the tube. Cutting a piece of gauze could result in entry of tiny shreds of the gauze the tracheostomy. The other interventions are appropriate.

The nurse is suctioning the secretions from a patient's endotracheal tube. The patient demonstrates a vagal response by a drop in heart rate to 54/min and a drop in BP to 90/55 mm Hg. After stopping suctioning, what is the nurses priority action? A. allow the patient to rest for at least 10 mins B. monitor the patient and call the Rapid Response team C. oxygenate with 100% oxygen and monitor the patient D. administer atropine according to standing orders

C

The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period? A. Computer keyboard B. Magic slate C. Picture board D. Pen and paper

C A picture board does not require very much dexterity for communication. Dexterity can be limited to the extent the client finds comfortable.

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur? a) suctioning of carbon dioxide b) prevention of suctioning c) loss of sterile field d) trauma to the tracheal mucosa

D

A patient has a cuffed trach tube without a pressure relief valve. To prevent tissue damage of the tracheal mucosa, what does the nurse do? A. deflate the cuff every 2 to 4 hours and maintain as needed B. change the tracheostomy tube every 3 days or per hospital policy C. assess and record cuff pressure each shift using the occlusive technique D. assess and record cuff pressure each shift using minimal leak technique

D

A patient with a permanent trach is interested in developing an exercise regime. Which activity does the nurse advise the patient to avoid? A. aerobics B. Tennis C. golf D. swimming

D

While the nursing student changes a patients trach dressing, the nurse observes the student using a pair of scissors to cut a 4X4 gauze pad to make a split dressing that will fit around the trach tube. What is the nurses best action? A. give the student positive reinforcement for use of materials and technique B. report the student to the instructor for remediation of the skill C. change the dressing immediately after the student has left the room D. direct the student in the correct use of materials and explain the rationale

D

A client with a tracheostomy is at increased risk for aspiration. Which nursing intervention(s) will reduce this risk? SELECT ALL THAT APPLY. A. Encourage frequent sipping from a cup B. Encourage water with meals C. Inflate the tracheostomy cuff during meals D. Maintain the client upright for 30 minutes after eating E. Provide small, frequent meals F. Teach the client to "tuck" the chin down in the forward position to swallow

DEF At least 30 minutes is required for thinner liquids in the stomach to be thickened in combination with stomach contents and/or removed from the stomach; this reduces the chance of aspiration. Eating requires significant time and energy. When the client becomes tired, he is more likely to aspirate. Shorter and more frequent intervals of eating tire the client less and reduce the chance of aspiration. Tucking the chin downward helps to open the upper esophageal sphincter.

For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube? A. Hyperoxygenate before and after suctioning B. Repeat suctioning until the tube is clear C. Apply suction during insertion of the tube D. Suction for 30 seconds

A The client should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client should be hyperoxygenated for 1-5 minutes, or until the client's baseline heart rate and oxygen saturation are within normal limits.`

A client has just arrived in the PACU following a successful tracheostomy procedure. Which nursing action must be taken first? A. Suction as needed B. Clean the tracheostomy inner cannula and stoma C. Listen to lung sounds D. Change the tracheostomy dressing as needed

C Assessment is the first phase of the nursing process. All other actions and procedures are driven by assessment findings. The first nursing action for a client following an airway procedure is to assess the client's respiratory status; this requires auscultation of the lungs.

The nurse is teaching a family member how to suction the client's tracheostomy at home. Which information does the nurse include in the teaching plan? a. Always suction using sterile technique. b. Suction the mouth first and then the airway. c. Be prepared to recannulate the tube frequently. d. Suctioning with clean technique is acceptable.

D The family member can suction using clean technique because fewer organisms are present in the home than in the hospital. Never suction the mouth first because airway pathogenic organisms could be introduced into the airway. The family member should not be required to recannulate the tube except in an emergency.

The client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about tracheostomy care? A. "I can only take baths, no showers." B. "I can put normal saline in my tracheostomy to keep the secretions from getting thick." C. "I should put cotton or foam over the tracheostomy hole." D. "I will have to learn to suction myself."

A The client does not understand that he can shower with the use of a shower shield over the tracheostomy tube to prevent water from entering the airway. Additional teaching is necessary.

The nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed? 1.The ties leave no marks on the neck. 2.The nurse places two fingers between the tie and the neck. 3.The tracheotomy can be pulled slightly away from the neck. 4.The nurse uses a 12-inch tie that is tightly affixed with hook-and-loop closures.

2

A patient has a temporary trach following surgery to the neck area to remove a benign tumor. Which nursing intervention is performed to prevent obstruction of the tracheostomy tube? A. Provide tracheal suctioning when there are noisy respirations B. Provide oxygenation to maintain pulse oximeter readings C. inflate the cuff to maximum pressure and check it once per shift D. suction regularly and as needed (prn) with an oral suction device

A

A patient is receiving preoperative teaching for a partial laryngectomy and will have a tracheostomy postoperatively. How does the nurse define a tracheostomy to the patient? A. opening in the trachea that enables breathing B. temporary procedure that will be reversed at a later date C. technique using positive pressure to improve gas exchange D. Procedure that holds open the upper airways

A

Which complication is the result of constant pressure exerted by a tracheostomy cuff causing tracheal dilation and erosion of cartilage? A. Tracheomalacia B. Tracheal stenosis C. Tracheoesophageal fistula D. Trachea-innominate artery fistula

A

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated? a. Use a manometer to ensure cuff pressure is at an appropriate level. b. Check the amount of cuff pressure ordered by the health care provider. c. Suction the patient first with a fenestrated inner cannula to clear secretions. d. Insert the decannulation plug before the nonfenestrated inner cannula is removed.

A Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the nonfenestrated inner cannula is removed. Otherwise, the patient's airway is occluded. A health care provider's order is not required to determine safe cuff pressure. A nonfenestrated inner cannula must be used to suction a patient to prevent tracheal damage occurring from the suction catheter passing through the fenestrated openings.

A patient sustained a serious crush injury to the neck and had a trach tube placed 3 days ago. As the nurse is performing trach care, the patient suddenly sneezes forcefully and the tube falls out onto the bed linens. What does the nurse do? A. ventilate the patient with 100% oxygen and notify the provider B. quickly and gently replace the tube with a clean cannula kept at the bedside C. quickly rinse the tube with sterile solution and gently replace it D. Give the patient oxygen; call for assistance and a new tracheostomy kit

B

A patient with a tracheostomy is unable to speak. He is not in acute distress, but is gesturing and trying to communicate with the nurse. Which nursing intervention is the best approach in this situation? A. reply on the family to interpret for the patient B. ask questions that can be answered with a yes or no response C. obtain an immediate consult with the speech therapist D. encourage the patient to rest rather than struggle with communication

B

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning attempt to a maximum of which time period? a. 5 seconds b. 10 seconds c. 30 seconds d. 60 seconds

B

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? a. 5 seconds b. 10 seconds c. 30 seconds d. 60 seconds

B

To prevent accidental decannulation of a tracheostomy tube, what does the nurse do? A. obtain an order for continuous upper extremity restraints B. secure the tube in place using ties or fabric fastners C.allow some flexibility in motion of the tube while coughing D. instruct the patient to hold the tube with a tissue while coughing

B

A patient who is breathing on his own has a fenestrated trach tube with a cuff. Which precaution must the nurse instruct the student about when caring for this patient? A. always keep the cuff inflated to prevent secretions from entering the lungs B. suction the patient every 30 to 60 minutes C. always deflate the cuff before capping the tube with the decannulation cuff D. To reduce the risk for tracheal damage, keep the cuff pressure between 22 and 30 mm Hg

C

An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? A. Complete the referral form for a home health agency B. Suction the tracheostomy using sterile technique C. Teach the client and spouse about tracheostomy D. Consult with the physician about using a fenestrated tube

B Complex sterile procedures are within the education, scope, and practice of the experienced LPN/LVN.

A patient with a trach is being discharged to home. In patient teaching, what does the nurse instruct the patient to do? A. use sterile technique when suctioning B. instill tap water into the artificial airway C. clean the trach tube with soap and water D. Increase the humidity in the home

D

A patient with a tracheostomy without a tube in place develops increased coughing, inability to expectorate secretions, and difficulty breathing. What are these assessment findings related to? A. overinflation of the pilot balloon B. tracheoesophageal fistula C. cuff leak and rupture D. tracheal stenosis

D

Patients with a tracheostomy or endotracheal tube need suctioning. Which nursing interventions apply to proper suctioning technique? Select all that apply A. preoxygenate the patient for at least 30 seconds before suctioning B. Instruct the patient that he or she is going to be suctioned C. quickly insert the suction catheter until resistance is met D. suction the patient for at least 30 seconds to remove secretions E. repeat suctioning as needed for to five total suction passes

ABC

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist? a. Leave the tracheostomy inner cannula inserted at all times. b. Place the decannulation cap in the tube before cuff deflation. c. Assess the ability to swallow before using the fenestrated tube. d. Inflate the tracheostomy cuff during use of the fenestrated tube.

C Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube.

Which statement by a client indicates an accurate understanding of home self-care of a tracheostomy? a. "The stoma should be left uncovered during the day to dry." b. "I need to put normal saline in my airway twice daily." c. "While showering, I need to keep water out of my airway." d. "I don't need to use tracheostomy ties on a daily basis."

C The client should put a shield over the tracheostomy to keep water from entering the airway. The airway should remain covered during the day with cotton or foam. Saline should be put in the airway 10 to 15 times daily. Tracheostomy ties should be used daily.

The client with a new tracheostomy has a soiled dressing. What is the best nursing intervention? A. Cut sterile 4 x 4 gauze to fit around the tracheostomy tube B. Reinforce the dressing with sterile 4 x 4 gauze C. Replace the dressing with clean, folded 4 x 4 gauze D. Replace the dressing with sterile, folded 4 x 4 gauze

D

A client is becoming frustrated because of an inability to communicate with a tracheostomy. Which intervention by the nurse most effectively enhances communication? a. Explain to the client that speech will be clear and distinct with a fenestrated tube. b. Reassure the client that in time he or she will get used to the speech difficulties. c. Place a sign above the client's bed indicating that the client cannot speak. d. Provide the client with a communication board and call light within easy reach.

D A communication board and the call light will reassure the client that needs will be communicated and met. It is doubtful that the client with a tracheostomy will ever speak clearly and distinctly, no matter what type of tube he or she uses. Reassuring the client that he or she will get used to the speech difficulties does nothing to alleviate the discomfort and fear associated with impaired communication. Placing a sign above the client's bed indicating that he cannot speak will not enhance his ability to communicate, although it may help staff remember that the client has impaired communication.

Respirations of the sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse? A. Humidifying the oxygen source B. Increasing oxygenation C. Removing the inner cannula of the tracheostomy D. Suctioning the client

D Suctioning the client will likely result in clear lung sounds and lower peak pressure, and the appearance of the sputum will indicate whether bleeding is a concern.