trach

2. A patient has extremely copious and thick oral secretions. The nurse provides oropharyngeal suctioning using a _________________ suction device.

Yankauer or tonsillar tip

7. The nurse is caring for a patient on mechanical ventilation with an endotracheal tube. Which nursing interventions will help prevent ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Changing the patient's position every 2 hours b. Keeping the head of the bed elevated 30 to 45 degrees c. Providing oral care with a toothette every 8 hours d. Keeping the head flat during and for 30 minutes after enteral feedings

a. Changing the patient's position every 2 hours b. Keeping the head of the bed elevated 30 to 45 degrees

8. The nurse is evaluating a patient to determine whether the endotracheal tube cuff is properly inflated. Which findings indicate proper inflation? (Select all that apply.) a. Exhaled tidal volume is 50 mL less than the tidal volume set on the ventilator. b. Air leak is heard with a stethoscope only at the end of inspiration. c. The patient is able to vocalize. d. Gastric contents are noted in airway secretions.

a. Exhaled tidal volume is 50 mL less than the tidal volume set on the ventilator. b. Air leak is heard with a stethoscope only at the end of inspiration.

6. A nurse is preparing to suction a patient via the nasotracheal route. Which conditions should the nurse recognize as contraindications to nasotracheal suctioning? (Select all that apply.) a. Motor vehicle accident with acute head injuries b. History of hemophilia c. Epiglottitis or croup d. Environmental allergies with sinus drainage

a. Motor vehicle accident with acute head injuries b. History of hemophilia c. Epiglottitis or croup

5. The nurse is caring for a patient who has a tracheostomy. To prevent the patient from developing an airway obstruction, the nurse assesses which of the following? (Select all that apply.) a. Patient's nutritional status b. Environmental humidity c. Existing respiratory infection d. Patient's ability to cough

a. Patient's nutritional status b. Environmental humidity c. Existing respiratory infection d. Patient's ability to cough

1. The nurse is assessing the risk for aspiration of gastric contents into the lungs resulting in airway obstruction. The nurse identifies patients with which conditions as having increased risk? (Select all that apply.) a. Presence of a gastrostomy feeding tube b. History of smoking 2 packs per day for 30 years c. Head injury with a decreased level of consciousness d. Stroke with dysphagia

a. Presence of a gastrostomy feeding tube c. Head injury with a decreased level of consciousness d. Stroke with dysphagia

4. The nurse is providing care to a patient on mechanical ventilation with an endotracheal tube. The nurse carefully inflates the cuff of the endotracheal tube using the minimal leak method, knowing that a properly inflated cuff provides which benefits to the patient? (Select all that apply.) a. Prevents aspiration of gastric contents b. Promotes accumulation of secretions below the epiglottis c. Prevents air from escaping between the tube and the tracheal wall d. Promotes lung inflation for mechanical ventilation

a. Prevents aspiration of gastric contents c. Prevents air from escaping between the tube and the tracheal wall d. Promotes lung inflation for mechanical ventilation

3. The nurse performing nasotracheal suctioning should be assessing the patient for which possible unexpected outcomes? (Select all that apply.) a. Severe reduction in heart rate b. Wheezing and inability to breathe c. Reduction in oxygen saturation d. Nasal bleeding

a. Severe reduction in heart rate b. Wheezing and inability to breathe c. Reduction in oxygen saturation d. Nasal bleeding

14. The nurse is preparing to suction an infant with a tracheostomy tube. Which action by the nurse follows appropriate procedure? a. Using a suction catheter that is half the diameter of the tracheostomy tube b. Suctioning 0.2 to 0.5 inches beyond the tip of the tracheostomy tube c. Hyperoxygenating with 90% oxygen to avoid oxygen toxicity d. Using less than 150 mm Hg negative pressure

a. Using a suction catheter that is half the diameter of the tracheostomy tube

2. A patient using a nasal cannula has gurgling on inspiration. The nurse notes a productive cough but the inability to clear the secretions from the mouth. Which action should the nurse take first to prepare for oropharyngeal suctioning? a.Apply clean gloves and a mask. b.Insert the suction device to the back of the throat. c.Remove the patient's nasal cannula. d.Connect the tubing to a standard suction catheter.

a.Apply clean gloves and a mask.

4. The nurse is caring for an infant who has been vomiting and is having difficulty breathing. What actions by the nurse are appropriate for suctioning the infant? a.Place the infant in a supine position. b.Suction only when a large amount of mucus is present. c.Suction for only 30 seconds. d.Compress the bulb syringe after it is placed in the nostril.

a.Place the infant in a supine position.

17. The nurse is assessing a patient who is intubated and on a ventilator. When listening above the sternal notch with a stethoscope, the nurse notes a minimal amount of air leak at the end of inspiration. Which action by the nurse is appropriate? a. Remove all air from the cuff and reinflate the cuff until no air leak is present. b. Note that the cuff is properly inflated. c. Notify the health care provider. d. Suction the patient.

b. Note that the cuff is properly inflated.

2. A patient with increased secretions may develop airway obstruction. The nurse can promote a patent airway by using which of the following techniques? (Select all that apply.) a. Limiting fluid intake b. Positioning c. Deep breathing d. Humidity

b. Positioning c. Deep breathing d. Humidity

23. The nurse is assessing a patient with an endotracheal tube and notes an audible air leak when standing by the patient. Which intervention should the nurse perform first to address this problem? a. Deflating the cuff of the endotracheal tube b. Repositioning the patient or tube c. Inserting a new endotracheal tube d. Notifying the health care provider

b. Repositioning the patient or tube

11. The nurse is performing nasotracheal suctioning on a patient. The nurse should discontinue the suctioning if which of the following occurs? a. The patient coughs as the catheter is inserted. b. The heart rate decreases from 84 beats per minute to 60 beats per minute. c. An increase in pulse occurs from 74 beats per minute to 94 beats per minute. d. Oxygen saturation levels decrease from 97% to 94%.

b. The heart rate decreases from 84 beats per minute to 60 beats per minute.

12. The nurse is suctioning a patient with an endotracheal tube. Which action should the nurse take when the patient develops respiratory distress? a. Quickly remove the catheter and carefully reinsert it. b. Continue to apply intermittent suction to remove thick secretions. c. Administer oxygen directly through the suction catheter. d. Withdraw the catheter and encourage the patient to cough and deep-breathe.

c. Administer oxygen directly through the suction catheter.

19. The nurse is providing care to a patient with a tracheostomy tube that has an inner cannula. Which intervention by the nurse follows proper procedure for tracheostomy tube care? a. Carefully removes the inner cannula and places it in a basin of 1:10 bleach solution b. Scrubs the inner cannula on the inside and outside with a 1:10 bleach solution c. After scrubbing the inner cannula, rinses it with normal saline d. Uses a wet 4 4 gauze and cleans the inside of the outer cannula

c. After scrubbing the inner cannula, rinses it with normal saline

10. The nurse is performing nasotracheal suctioning for a patient. Which action by the nurse is appropriate? a. Applying intermittent suctioning while slowly withdrawing the suction catheter b. Carefully pushing the suction catheter in and out while applying suction c. Applying suction for 15 seconds or less d. Asking the patient to deep-breathe for 15 seconds before passing the catheter a second time

c. Applying suction for 15 seconds or less

8. The student nurse is preparing to perform nasotracheal suctioning on an adult patient wearing a face mask. Which action by the student should the nursing instructor question? a. Increasing the oxygen flow rate for the face mask and asking the patient to deep-breathe slowly before suctioning b. Inserting the catheter into the nares slanting slightly downward c. Asking the patient to swallow while the catheter is being inserted d. Inserting the catheter about 8 inches without applying suction

c. Asking the patient to swallow while the catheter is being inserted

20. A patient with a tracheostomy tube is accidentally extubated. What should the nurse do immediately? a. Call the health care provider. b. Mechanically ventilate the patient. c. Insert a new tracheostomy tube. d. Hold the stoma open with the fingertips.

c. Insert a new tracheostomy tube.

9. The nurse is providing nasotracheal suctioning for a 13-year-old patient with secretions in the throat and trachea. Which action by the nurse demonstrates proper technique? a. Applying sterile petroleum jelly to the distal tip of the suction catheter b. Applying clean gloves to both hands c. Inserting the suction catheter 6 to 8 inches during inspiration d. Suctioning the pharynx first and then the trachea

c. Inserting the suction catheter 6 to 8 inches during inspiration

15. A patient has been on mechanical ventilation with an endotracheal tube for 1 week. Which intervention by the nurse will help prevent ventilator-associated pneumonia (VAP)? a. Providing oral care with a toothbrush at least twice daily b. Changing the ventilator circuits at least every 72 hours c. Removing subglottal secretions before every position change d. Maintaining endotracheal cuff pressures at 10 cm H2O

c. Removing subglottal secretions before every position change

5. A patient on mechanical ventilation with an endotracheal tube requires suctioning. A closed in-line catheter is in place. Which action by the nurse is appropriate? a.Use manual ventilation to hyperoxygenate the patient with 100% oxygen via Ambu bag. b.Push the catheter and slide the plastic sleeve back when the patient exhales. c.Push the catheter in until resistance is felt or the patient coughs. d.Apply suction for no longer than 30 seconds as you remove the catheter.

c.Push the catheter in until resistance is felt or the patient coughs.

6. The nurse is assessing several patients who have returned from surgery. Which finding most likely indicates a need for suctioning? a.Complaint of pain when breathing b.Cough producing thick yellow mucus c.oxygen saturation level of 88% d.Drowsiness and respiratory rate of 8

c.oxygen saturation level of 88%

21. When assessing a patient's tracheostomy site, the nurse notes redness and inflammation around the stoma. Which intervention can the nurse provide to address this problem? a. Decrease the frequency of tracheostomy care. b. Apply a dry gauze dressing just under the stoma. c. Remove the ties at frequent intervals. d. Apply a topical antibacterial solution and allow it to dry.

d. Apply a topical antibacterial solution and allow it to dry.

18. The student nurse is providing tracheostomy care to a patient who has intratracheal secretions and a damp tracheostomy dressing and ties. Which action by the student should the nursing instructor question? a. Suctioning the tracheostomy tube before removing the soiled tracheostomy dressing b. Assisting the patient to semi-Fowler's position c. Placing new tracheostomy ties before cutting the old ties d. Cutting gauze pads to place around the tracheostomy tube

d. Cutting gauze pads to place around the tracheostomy tube

13. The nurse has completed suctioning a patient's airway. Which action should the nurse take first? a. Reduce the suction level to medium. b. Remove the face shield and save for future suctioning. c. Reposition the patient and assist with oral hygiene using sterile gloves. d. Pull the gloves off over the rolled catheter and discard.

d. Pull the gloves off over the rolled catheter and discard.

16. The nurse is caring for a patient with an oral endotracheal tube in place. Which intervention by the nurse demonstrates proper procedure when providing endotracheal tube care? a. Determining proper endotracheal tube depth by noting the length of tube beyond the gum line b. Instructing the assistant to hold the tube away from the lips while changing the tape c. Removing the oral airway if the patient is actively biting down after the tape is removed from the endotracheal tube d. Repositioning the tube on the opposite side or at the center of the mouth at least every 24 to 48 hours

d. Repositioning the tube on the opposite side or at the center of the mouth at least every 24 to 48 hours

22. The nurse is assessing a patient with an endotracheal tube on mechanical ventilation. Which assessment finding indicates a partially deflated cuff? a. Increased exhaled tidal volume b. Spasmodic coughing c. Tense test balloon on the endotracheal tube d. Vocalizations by the patient

d. Vocalizations by the patient

3. After oropharyngeal suctioning of a patient, the nurse notes bloody secretions in the suction catheter and tubing. What should the nurse do next? a.Increase the suction pressure. b.Provide additional oxygen. c.Reduce the frequency of oral hygiene. d.Check the suction catheter for nicks.

d.Check the suction catheter for nicks.

1. A patient with a tracheostomy tube has thick, tenacious mucus that is difficult to remove. The nurse should choose which technique to suction the airway? a.Normal saline instillation (NSI) before suctioning b.Dry suctioning 1 time followed by NSI with suctioning 2 more times c.Dry suctioning as long as the heart rate is above 60 beats/min d.Dry suctioning

d.Dry suctioning

7. A patient with head trauma following a motor vehicle accident is on mechanical ventilation with an endotracheal tube. Which action by the nurse will reduce the risk for elevations in intracranial pressure during suctioning? a.Avoid hyperoxygenating the patient before suctioning. b.Insert the suction catheter just to the end of the endotracheal tube. c.Apply suction while inserting the catheter. d.Limit suctioning to 2 times with each suctioning procedure.

d.Limit suctioning to 2 times with each suctioning procedure.

3. A plastic or rubber tube that is inserted through the nares or mouth past the epiglottis and vocal cords to maintain an airway is known as an _________________.

endotracheal (ET) tube

1. Too much oxygen reduces the drive to breathe in patients with chronic _____________.

hypercapnia

4. A _______________ is inserted directly into the trachea through a small incision made in the patient's neck.

tracheostomy tube