trach care/suctioning

The nurse is caring for a patient who has had a craniotomy. The patient appears to need endotracheal suctioning. The nurse is aware that this can be of concern because suctioning can cause which of the following? (Select all that apply.) a.Violent coughing b.Aspiration of stomach contents c.Increased intracranial pressure d.Bradycardia or tachycardia

a.Violent coughing b.Aspiration of stomach contents c.Increased intracranial pressure d.Bradycardia or tachycardia

A nurse is caring for four clients. After receiving the hand-off report, which client should the nurse see first? a. Client having a radial neck dissection tomorrow who is asking questions b. Client who had a tracheostomy 4 hours ago and needs frequent suctioning c. Client who is 1 day postoperative for an oral tumor resection who is reporting pain d. Client waiting for discharge instructions after a small tumor resection

b. Client who had a tracheostomy 4 hours ago and needs frequent suctioning

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. Administer prescribed anxiolytic medication. b. Ensure informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.

b. Ensure informed consent is on the chart.

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the clients bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.

b. Measure and compare cuff pressures.

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.

b. The client has joined a book club that meets at the library.

The nurse will train the tracheostomy patient and caregiver that reusable supplies need to be disinfected at least weekly. Which of the following methods is recommended for cleaning tracheostomy supplies at home? (Select all that apply.) a.Boil reusable (boilable) supplies for 5 minutes. Allow to cool and dry. b.Boil reusable (boilable) supplies for 15 minutes. Allow to cool and dry. c.Soak reusable supplies in equal parts of vinegar and water for 30 minutes. Remove, rinse thoroughly, and dry. d.Soak reusable supplies in prepared solutions of quaternary ammonium chloride compounds according to the manufacturers instructions. Rinse and dry.

b.Boil reusable (boilable) supplies for 15 minutes. Allow to cool and dry. c.Soak reusable supplies in equal parts of vinegar and water for 30 minutes. Remove, rinse thoroughly, and dry. d.Soak reusable supplies in prepared solutions of quaternary ammonium chloride compounds according to the manufacturers instructions. Rinse and dry.

The nurse is planning home care for a 2-year-old child with a tracheostomy. What recommendation should be included? a.Sterile technique is essential in home care of the tracheostomy. b.Parents are able to change the tracheostomy tube when needed. c.Play activities must be sedentary such as listening to music and working on puzzles. d.The child must wear a plastic bib when eating or drinking to prevent aspiration into the stoma.

b.Parents are able to change the tracheostomy tube when needed.

The nurse must suction a 6-month-old infant with a tracheostomy. What intervention should be included? a.Encourage the child to cough to raise the secretions before suctioning. b.Perform each pass of the suction catheter for no longer than 5 seconds. c.Allow the child to rest after every five times the suction catheter is passed. d.Select a catheter with a diameter three quarters of the diameter of the tracheostomy tube.

b.Perform each pass of the suction catheter for no longer than 5 seconds.

The nurse is caring for a child with a tracheostomy. What clinical manifestation should the nurse recognize as an early sign of impending respiratory distress or failure? a.Cyanosis b.Restlessness c.Audible stridor d.Crowing respirations

b.Restlessness

A client had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is the priority? a. Delegate oral care every 4 hours. b. Monitor and record the clients intake. c. Place the client in a high-Fowlers position. d. Remove the inner cannula for cleaning.

c. Place the client in a high-Fowlers position.

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

c. Tying a square knot at the back of the neck

A patient with a tracheostomy tube has an order for oxygen. Which action by the nurse is appropriate? a.Apply sterile gloves to connect the oxygen to the tracheostomy tube. b.Check the oxygen tubing frequently to make sure water is present in the tubing. c.Attach the T tube to a humidified oxygen source. d.Monitor the response to oxygen with hourly arterial blood gas levels.

c.Attach the T tube to a humidified oxygen source.

A 3-year-old child with a tracheostomy will soon be discharged. What recommendation should the nurse share with the family? a.Tub baths cannot be given. b.The child cannot be allowed to play outdoors. c.Avoid exposure to noxious fumes such as paint or varnish. d.Cover the tracheostomy with a plastic bib when exposed to cold air.

c.Avoid exposure to noxious fumes such as paint or varnish.

When teaching the patient about performing trach care, which of the following is an acceptable technique? a.Remove the old ties before applying the new. b.Keep two trach tubes of the same size at the bedside. c.Place the new trach tie, then remove the old tie. d.Dispose of all old supplies and replace with new.

c.Place the new trach tie, then remove the old tie.

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the provider immediately.

d. Stay with the client and have someone else call the provider immediately.

The nurse is teaching the patient and family how to perform tracheal suctioning. What does proper technique include? a.Teaching how to instill normal saline before suctioning b.Suctioning the nasal and oral pharynx before the trachea c.Encouraging daily brushing of the teeth and oral hygiene d.Having the patient take two to three deep breaths after the procedure

d.Having the patient take two to three deep breaths after the procedure

What is the principal difference in tracheostomy care between care given in the acute care setting and care given in the home care environment? a.In the acute care setting, the inner cannula is cleaned. b.In the home care setting, dressings are not necessary. c.in the acute care setting, hydrogen peroxide is used for cleaning. d.In the home care setting, the procedure may be done with clean technique.

d.In the home care setting, the procedure may be done with clean technique.

A ___________________ delivers oxygen through a catheter permanently inserted into the trachea, thus allowing the patient to speak and bypassing anatomical dead space.

transtracheal oxygen catheter

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

a. Applying suction while inserting the catheter

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying water-soluble lip balm to the clients lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy

a. Applying water-soluble lip balm to the clients lips d. Reminding the client to cough and deep breathe often

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the clients oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.

a. Assess the clients oxygen saturation.

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision

a. Cognition b. Dexterity d. Range of motion e. Vision

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Dont go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

a. Create a communication system. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

The patient has just had a tracheostomy tube placed and is expectorating copious amounts of sputum that he coughs forcefully from his tracheostomy tube. The patient also is suspected of having methicillin-resistantStaphylococcus aureus (MRSA) in his sputum. The nurse is preparing to suction the patient to clear his airway. Which of the following will the nurse need to wear if following standard precautions? (Select all that apply.) a.Mask b.Goggles c.Gown d.Sterile gloves

a.Mask b.Goggles c.Gown d.Sterile gloves

What is an expected outcome after tracheostomy care is successfully performed? a.A stoma site that is hard to the touch b.An inner cannula that is free of secretions c.Copious secretions obtained from suctioning d.Bloody secretions that have been suctioned

b.An inner cannula that is free of secretions