Module 17: Tracheostomy Care

The nursing is auctioning a clients tracheostomy using an open system. For which action should the nursing use the gloves, dominant hand? A. Manipulating the suction catheter B. Hyperventilating the client with a manual resuscitation bag C. Connecting the section to be to the suction catheter D. Controlling the suction valve on the catheter

A. Manipulating the suction catheter

When suctioning the tracheostomy, when would the nurse suction the oral cavity? A. Shortly after suctioning the tracheostomy. B. 1 to 2 hours after suctioning the tracheostomy C. Just prior to suctioning the tracheostomy. D. Simultaneously while suctioning the tracheostomy

A. Shortly after suctioning the tracheostomy.

While providing care to a client who has a tracheostomy with a nondtsposable inner cannula, the nurse observes secretions that have accumulated in the outer cannula. Which action would the nurse take? A. Suction the outer cannula using strict aseptic technique. B. Encourage the to cough up the secretions. C. Gently clean the outer cannula with the brush used to clean the inner cannula. D. Wipe the secretions away with a tissue.

A. 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? A. Use each applicator only oncemoving from the stoma site outward. B. Clean the faceplate avoiding the area around the stoma C. Dip a cotton-tipped applicator into a cup of sterile water. D. Allow the skin to air dry for 30 seconds before applying the dressing.

A. Use each applicator only oncemoving from the stoma site outward.

The nurse has just finished suctioning a client with a tracheostomy. Which action should the nurse take next? A. Document the procedure and client tolerance. B. Assess the client's lung sounds. C. Ask the client any pain medication is needed. D. Remind the client to use the call bell when needed.

B. Assess the client's lung sounds.

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? A. Rinse off the expelled tracheostomy with sterile saline and reinsert it using the obturator. B. Notify the health care provider. C. Insert the obturator into a new tracheostomy and insert the tracheostomy into the stoma. D. Replace the collar on the expelled tracheostomy and reinsert using the obturator

C. 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 ? A. Once the procedure started we will not interrupt it so that we do not cause additional pain B. I've done this procedure many times and it has not caused a great amount of pain in any of my clients C. Try to relax a little the more anxious you are the more pain you'll experience D. If you experience any difficulty squeeze my hand and I will stop to allow you to rest a bit

D. If you experience any difficulty squeeze my hand and I will stop to allow you to rest a bit

On assessment, the nurse notes that the tracheostomy ties are grossly soiled and require changing . No one is available to assist at this time. What is the best action by the nurse? A. Wait until later when someone is available to assist with the change. B. the in the importance of not coughing during the procedure. C. Remove the soiled ties and tape the tracheostomy collar securely in place. D. Secure the new tracheostomy ties before removing the old

D. Secure the new tracheostomy ties before removing the old

When suctioning a client with the tracheostomy using an open system, with actions by the nurse would help to prevent hypoxemia during the procedure. Select all that apply

Limit suctioning to 10 to 15 seconds each time. Hyperventilating client with 3 to 6 breast before suctioning Pause for 30 to 60 seconds between sectioning attempts

The nurse is changing a disposable inner cannula on a tracheostomy client, Place order , from first to last, the actions the nurse will perform. Use all options. 1. Remove and discard clean gloves, and put on sterile gloves. 2. Remove oxygen source to tracheostomy if present. 3. Use dominant hand to pick up the new inner cannula, and insert the outer cannula 4. Remove Inner cannula and site dressing and place them in disposable bag. 5. Open supplies using aseptic technique. 6. Use nondominant hand to stabilize the outer cannula and faceplate.

1. Open supplies using aseptic technique. 2. Remove oxygen source to tracheostomy if present. 3. Use nondominant hand 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 hand to pick up the new inner cannula, and insert the outer cannula

The nurse has assessed a client with a tracheostomy and decided that suctioning needed. Which action will the nurse implement to help prevent complications? A. Suction the trachea only after suctioning the oropharynx B. Suction the mouth first, and then insert the catheter in the tracheostomy. C. Limit suctioning passes to no more than three per episode. D. Allow a 2-minute interval between suctioning passes.

C. Limit suctioning passes to no more than three per episode.

Place in order, from first to last, the actions the nurse will perform when preparing to suction an alert client tracheostomy using an open system, Use all options. 1. Adjust the wall suction to the appropriate level. 2. Explain the procedure to the client. 3. Open sterile packages and set up sterile field. 4. Auscultate the client's lung sounds for evaluation of the intervention 5. Don sterile gloves. 6. Adjust the bed and position the client.

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

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? A. Withdraw the catheter at least 0.5 (1.25 cm) before applying suction. B. Remove the catheter and notify the health care provider. C. Remove the catheter and insert a new one. D. Insert saline into the port to clean the catheter and advance the tubing again.

A. Withdraw the catheter at least 0.5 (1.25 cm) before applying suction.

The nurse is inserting the suction catheter into a client's tracheostomy and suddenly meets resistance. Which action would be most appropriate? A. Withdraw the catheter at least 0.5 in (1.25 cm). B. Continue inserting the catheter another inch (2.5 cm) C. Apply suction to the catheter. D. Rotate the catheter one half-turn.

A. Withdraw the catheter at least 0.5 in (1.25 cm).

The nurse is suctioning a client with a tracheostomy using an open system device. Which action will the nurse implement specifically to help prevent trauma to the tracheal tissue?

Apply section at 110 to 130 mm Hg from the wall unit

The nurse is preparing to section the tracheostomy of a client. The nurse will place which client in the lateral position facing the nurse? A. Client who is confusing or uncooperative B. Unconscious client after abdominal surgery C. Conscious teenager with trauma to the trachea D. Conscious client who had hip surgery

B. Unconscious client after abdominal surgery

After changing the disposable inner cannula and changing the dressing of a client who has a tracheostomy , a nurse prepares to change the client's tracheostomy collar. Which action would the nurse take first? A. Keep the old collar in place until the new collar secured. B. Enlist the assistance of a second nurse. C. the first hook-and-loop fastener strap out of the opening on the faceplate. D. Ask the client to take a deep breath and remove the collar in one piece.

B. Enlist the assistance of a second nurse.

On assessment, the nurse notes significant secretions on the client's tracheostomy dressing. The health care provider's prescription states that tracheostomy site care is to be done once per shift. The nurse has already performed site care once during the current shiftWhat the best action by the nurse? A. Notify the health care provider and request additional prescription. B. Perform site care again and document the procedure. C. Wipe the secretions off the dressing as best as possible. D. Request that the nurse on the next shift change the dressing

B. Perform site care again and document the procedure.

The nurse is providing site care for a client with a tracheostomy using a nandisposable inner cannula, Which step is recommended to release the lock on the device? A. Stabilize the outer cannula and faceplate with the dominant hand. B. Stabilize the outer cannula and faceplate with the nondominant hand. C. Rotate the inner cannula counter-clockwise using the nondominant hand. D. Rotate the inner cannula clockwise using the dominant hand

B. Stabilize the outer cannula and faceplate with the nondominant hand.

The 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? A. Apply water-soluble lubricant around the stoma. B. Use two folded gauze sponges on each side of the stoma. C. Wait until a commercially prepared dressing becomes available. D. Cut a small slit in a sterile gauze pad.

B. Use two folded gauze sponges on each side of the stoma.

After assessing clients with a tracheostomy, which client will the nurse suction? A. A client who has not been suctioned in more than 4 hours. B. A client with an oxygen saturation of 97% pulse oximetry. C. A client with a diminished gag reflex because of stroke. D. A client with rhonchi in upper airways noted on auscultation.

D. A client with rhonchi in upper airways noted on auscultation.

The nurse if providing tracheostomy care to a client with a nondisposable inner cannula. Which action should the nurse take next after removing the inner cannula? A. Place the inner cannula a sterile alcohol solution to soak. B. Suction the client using sterile technique. C. Use a pipe cleaner and sterile saline to clean the lumen of the inner cannula. D. Replace the client's oxygen source over the outer cannula.

D. Replace the client's oxygen source over the outer cannula.

The nurse is observing a student nurse suction a client with a tracheostomy using an open system. Which action by the student nurse will require additional instruction by the nurse? The student nurse: A. pauses for 45 seconds between suction attempts and encourages the client to cough. B. uses the nondominant hand to connect the suction tubing to the suction catheter. C. adjusts the wall suction to 130 mm Hg on a wall unit. D. uses a manual resuscitation bag to give the client big breaths before beginning.

D. uses a manual resuscitation bag to give the client big breaths before beginning.

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? A. Apply a topical analgesic around the tracheostomy stoma site. B. Hyperventilate the client with a manual resuscitation bag. C. Assess the client for pain and administer analgesic as needed. D. Ensure that any oxygen source tightly secured to the tracheostomy

C. Assess the client for pain and administer analgesic as needed.

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? A. Gently rotating the suction catheter as it is being withdrawn B. Using only the dominant hand to handle and manipulate the catheter C. Applying section only during insertion of the suction catheter D. Using the dominant hand to open and close the section port

B. Using only the dominant hand to handle and manipulate the catheter

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. Grasp the suction catheter through the protective sheath 3. Turn on the suction at the wall . 4. Assess the client's respiratory status for improvement 5. Withdraw the catheter while applying intermittent suction

1. Explain the procedure to the client. 2. Turn on the suction at the wall . 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 observing a family caregiver doing a return demonstration of tracheostomy care for a client with a nondisposable cannula action by the family caregiver indicates that additional teaching is required? A. The family caregiver performs hand hygiene, then dons clean gloves and a face shield to begin the procedure. B. The family caregiver rotates the inner cannula clockwise with the nondominant hand to release the lock. C. The family caregiver raises the bed to the caregiver's elbow level and raises the head of the bed to semi-Fowler's. D. The family caregiver agitates the inner cannula in a basin of sterile saline after cleaning it with the brush

B. The family caregiver rotates the inner cannula clockwise with the nondominant hand to release the lock.

Which client is most likely to need administration of pain medication before being suctioned the tracheostomy? A. Client who has a toe amputation B. Client with diabetes mellitus C. Client who had abdominal surgery D. Client with bilateral pneumonia

C. Client who had abdominal surgery

The nurse is providing tracheostomy care to a client and is preparing to change the client's tracheostomy collar. Which action would be most appropriate? A. Hold the tracheostomy tube in place with the nondominant hand while changing the collar with the dominant hand. B. Enlist the help of two other nurses, one to stabilize the client's neck and the other to hold the tube place during the process. C. 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. D. Check the fit of the tracheostomy collar after applying it, confirming that three fingers can be inserted between the neck and the collar .

C. 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 providing tracheostomy care for a client and cleans the nondisposable inner cannula with the brush. What should the surse do next? A. Apply a water-based lubricant to the inner cannula. B. Dry the inner cannula with a sterile, precut gauze. C. Place the inner cannula a basin of sterile saline. D. the inner cannula in a basin of hydrogen peroxide.

C. Place the inner cannula a basin of sterile saline.

When providing tracheostomy care a client with a disposable Inner cannula, at which point would the nurse put on sterile gloves? A. before opening the package containing the new cannula B. before the sterile cup with saline C. after removing the old inner cannula D. after opening the cotton-tipped applicators

C. after removing the old inner cannula

After changing a client's tracheostomy holder, the nurse determines that the collar fits properly when: A. the faceplate is centered. B. the hook andloop fastener tabs are adhered together. C. the client can flex the neck comfortably. D. two fingers fit under the holder.

C. the client can flex the neck comfortably.