NUR 214 Trach Management

After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent:

After suctioning, the client should rest at least 3 minutes or until respirations return to normal before suctioning is repeated, unless secretions interfere with breathing. Intermittent suctioning prevents oxygen deprivation. Hypoxia can lead to cardiac arrhythmias and cardiac arrest. The client should receive 100% oxygen between suctionings.

Which measure should the nurse perform when suctioning a tracheostomy tube?

Clients are hyperoxygenated before suctioning to prevent hypoxia. Suction is never applied while inserting the catheter into the airway. Laryngectomy tubes are not changed after suctioning. The suction catheter should be about half the diameter of the tube; a larger-diameter suction catheter would interfere with airflow during the procedure.

A client with cancer of the throat had a tracheostomy tube inserted 2 days ago. The client has moderate secretions and can take deep breaths without pain. When suctioning a client's tracheostomy tube, the nurse should take which action?

Preoxygenating the client before suctioning helps prevent the development of hypoxia during the procedure. The suction catheter is inserted about 12.7 to 15 cm (5 to 6 inches) into the cannula. A bolus of 3 to 5 mL of sterile normal saline solution may be inserted into the cannula before suctioning to stimulate coughing and loosen secretions. The nurse uses sterile technique when suctioning a client, not clean technique.

To more easily remove thick, tenacious secretions when suctioning a tracheostomy, the nurse should liquefy the secretions before suctioning by instilling the tracheostomy tube with 1 to 2 mL of which sterile solution?

Sterile normal saline is the solution of choice for instillation into a tracheostomy tube cannula to help liquefy sticky secretions. Normal saline solution is less irritating to mucous membranes than plain water, bacteriostatic water, or a dextrose solution.

The nurse is preparing to suction a tracheostomy for a client with methicillin-resistant Staphylococcus aureus (MRSA). What should the nurse do next?

The nurse is wearing protective personnel equipment appropriate for suctioning the client: goggles, gown, and respirator mask. It is not necessary to wear a PAPR face shield to suction a tracheostomy. A surgical mask does not provide maximum protection. The nurse must wear protective personnel equipment when caring for a client with a MRSA infection.

You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? Airway patency Level of consciousness Psychological status Pain level

The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation. The priorities are always airway, breathing, and then circulation.

The nurse is suctioning a tracheostomy for a client who had the tracheostomy tube placed 3 days ago. Which is the correct procedure for suctioning at this time?

The recommended technique is to use a sterile catheter each time the client is suctioned. There is a danger of introducing organisms into the respiratory tract when strict aseptic technique is not used. Reusing a suction catheter is not consistent with aseptic technique. The nurse does not use a clean catheter when suctioning a tracheostomy or a laryngectomy; it is a sterile procedure.

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? "Clean the tracheostomy tube with alcohol and water." "Family members should continue to talk to the client." "Oral intake of fluids should be limited for 1 week only." "Limit the amount of protein in the diet."

You Selected: "Oral intake of fluids should be limited for 1 week only." Correct response: "Family members should continue to talk to the client." Explanation: Commonly, family members are reluctant to talk to the client who has had a total laryngectomy and can no longer speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing.

The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?

You Selected: Monitor the pressure in the cuff at least every 8 hours Correct response: Monitor the pressure in the cuff at least every 8 hours Explanation: Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the patient from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure?

To change a tracheostomy dressing effectively, the client should rinse around the clean incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline - not full-strength hydrogen peroxide. The client shouldn't use tap water, which may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of non-raveling material instead of cotton-filled gauze squares.

A client requires long-term ventilator therapy. The client has a tracheostomy in place and requires frequent suctioning. Which technique should the nurse use? intermittent suction while advancing the catheter continuous suction while withdrawing the catheter intermittent suction while withdrawing the catheter continuous suction while advancing the catheter

To prevent hypoxia, the nurse should use intermittent (not continuous) suction while withdrawing the catheter. Suctioning shouldn't last more than 10 seconds at a time. Neither intermittent nor continuous suctioning should be applied while the catheter is being advanced.

student observes a nurse instilling a small amount of saline into a tracheostomy tube before suctioning. What should the student discuss with the nurse?

Previously, it was common practice to instill a small amount of normal saline into the tracheostomy tube during suctioning to help liquefy secretions. This is no longer recommended because the addition of saline into the airway further reduces oxygenation, has no effect on thinning secretions, and may dislodge bacteria adhering to the tube and flush it into the lungs.

Which choice demonstrates best nursing practice when performing tracheostomy care on a client who is 8 hours post new insertion?

The tracheotomy site is a portal of entry for microorganisms. Sterile technique must be used within the first 24-48 hours because the site is a new source of infection. Monitoring the client's temperature is not reflected in application of this question. Povidone-iodine destroys new cellular growth, so it is not used on open wounds. The client should be in high Fowler's, not semi-Fowler's position.

A nurse suctioning a patient 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?

You Selected: Trauma to the tracheal mucosa Correct response: Trauma to the tracheal mucosa Explanation: Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide, from the respiratory tract. Suctioning during insertion of the catheter would not compromise sterility.

A nurse is caring for a client who recently underwent a tracheostomy. What is the nurse's first priority when caring for this client? using a letter board for communication suctioning to keep the airway patent encouraging coughing and deep breathing turning from side to side to mobilize secretions

You Selected: suctioning to keep the airway patent Correct response: suctioning to keep the airway patent Explanation: Maintaining a patent airway is the most basic and critical human need. Helping the client communicate, encouraging the client to cough and breathe deeply, and turning the client are important actions, but are not the priority.