Skills Lab Chp. 17

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

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 changing a disposable inner cannula on a tracheostomy client. Place in order from first to last, the action the nurse will perform

1. open supplies using aseptic technique 2. remove oxygen source to tracheostomy if present 3. use nondominant had 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 had 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

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

The nurse is providing tracheostomy care to a client and is preparing to change the client's tracheostomsy 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 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

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.

Pause for 30 to 60 seconds between suctioning attempts. Limit suctioning to 10 to 15 seconds each time. 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 sute care isto 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 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 nurse is observing a family caregiver doing a return demonstration of a tracheostomy care for a client with a nondisposable inner cannula. Which action by the family caregiver indicates that addidtional teaching is required?

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

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 2 folded gauze sponges on each side of the stoma

The nurse is observing a student nurse suction a client with a tracheostomy using an open system. The student nurse:

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

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 (1.25cm)

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

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 suctioning a client with a tracheosotmy 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 130mmHg from the wall unit.

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 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

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 passses to no more than three per episode

The nurse is 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

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

Shortly after suctioning the tracheostomy

While providing care to 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 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

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 (1.25cm) before applying suction

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 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

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