ch. 27 (Tracheostomy)

Which nursing action would be of highest priority when suctioning a patient with a tracheostomy? a. Auscultating lung sounds after suctioning is complete b. Providing a means of communication for the patient during the procedure c. Assessing the patient's oxygenation saturation before, during, and after suctioning d. Administering pain and/or antianxiety medication 30 minutes before suctioning

Correct answer: a Rationale: The ability to swallow secretions without aspiration has traditionally been evaluated with the use of blue dye. A teaspoon of water colored with blue dye is swallowed by the patient. Respiratory secretions are then monitored for 24 hours for appearance of the dye, which would indicate aspiration. Recent studies, however, do not support the sensitivity of this test. It is therefore no longer recommended. Instead, clinical assessment by a speech therapist, videofluoroscopy, or fiberoptic endoscopic evaluations of swallow are recommended. Patients should begin swallowing with thickened liquids, not plain water. Ability to swallow should be assessed with the cuff deflated, inasmuch as cuff inflation may interfere with swallowing ability.

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when he coughs and expels the tracheostomy tube. How should the nurse respond? a. Suction the tracheostomy opening. b. Maintain the airway with a sterile hemostat. c. Use an Ambu bag and mask to ventilate the patient. d. Insert the tracheostomy tube obturator into the stoma.

Correct answer: b As long as the patient is not in acute respiratory distress after dislodging the tracheostomy tube, the nurse should use a sterile hemostat to maintain an open airway until a sterile tracheostomy tube can be reinserted into the tracheal opening. The tracheostomy is an open surgical wound that has not had time to mature into a stoma. If the patient is in respiratory distress, the nurse will use an Ambu bag and mask to ventilate the patient temporarily.

A 62-year-old male has a tracheostomy tube after reconstructive surgery for invasive head and neck cancer. What is most important for the nurse to assess before performing tracheostomy cannula care? a. Level of consciousness b. Quality of breath sounds c. Presence of the gag reflex d. Tracheostomy cuff pressure

Correct answer: b Before performing tracheostomy care, the nurse will auscultate lung sounds to determine the presence of secretions. To prevent aspiration, secretions must be cleared either by coughing or by suctioning before performing tracheostomy cannula care.

Which task can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP) in the care of a stable patient who has a tracheostomy? a. Assessing the need for suctioning b. Suctioning the patient's oropharynx c. Assessing the patient's swallowing ability d. Maintaining appropriate cuff inflation pressure

Correct answer: b Providing the individual has been trained in correct technique, UAP may suction the patient's oropharynx. Assessing the need for suctioning should be performed by an RN or licensed practical nurse, whereas swallowing assessment and the maintenance of cuff inflation pressure should be performed solely by the RN.

When using a prosthesis for transesophageal speech, the patient a. places a vibrating device in the mouth. b. blocks the stoma entrance with a finger. c. swallows air using a Valsalva maneuver. d. places a speaking valve next to the stoma.

Correct answer: b Rationale: To use a prosthesis for transesophageal speech, the patient manually blocks the stoma with a finger. Air moves from the lungs through the prosthesis, into the esophagus, and out the mouth. Speech is produced by the air vibrating against the esophagus and is formed into words by movement of the tongue and lips.

What is the priority nursing assessment in the care of a patient who has a tracheostomy? a. Electrolyte levels and daily weights b. Assessment of speech and swallowing c. Respiratory rate and oxygen saturation d. Pain assessment and assessment of mobility

Correct answer: c The priority assessment in the care of a patient with a tracheostomy focuses on airway and breathing. These assessments supersede the nurse's assessments that may also be necessary, such as nutritional status, speech, pain, and swallowing ability.

All of the following care tasks are needed by a patient admitted for joint replacement surgery who has had a permanent tracheostomy for over 10 years. Which task is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Suction the tracheostomy. b. Check stoma site for skin breakdown. c. Complete tracheostomy care using sterile technique. d. Provide oral care with a toothbrush and tonsil suction tube.

Correct answer: d Oral care (for a stable patient with a tracheostomy) can be delegated to UAP. A registered nurse would be responsible for assessments (e.g., checking the stoma for skin breakdown) and tracheostomy suctioning and care.