310: Ch. 28 Tracheostomy

A patient has a temporary trach following surgery to the neck area to remove a benign tumor. Which nursing intervention is performed to prevent obstruction of the tracheostomy tube? A Provide tracheal suctioning when there are noisy respirations B Provide oxygenation to maintain pulse oximeter readings C inflate the cuff to maximum pressure and check it once per shift D suction regularly and as needed (prn) with an oral suction device

A

A patient is receiving preoperative teaching for a partial laryngectomy and will have a tracheostomy postoperatively. How does the nurse define a tracheostomy to the patient? A opening in the trachea that enables breathing B temporary procedure that will be reversed at a later date C technique using positive pressure to improve gas exchange D Procedure that holds open the upper airways

A

The nurse is caring for a patient with a tracheostomy who has recently been transferred from the ICU. but he has no unusual occurrences related to the tracheostomy or his oxygenation status. What does the routine care for this patient include? A thorough respiratory assessment at least every 2 hours B maintaining the cuff pressure between 50 and 100 mm Hg C Suctioning as needed; maximum suction time of 20 seconds D changing the tracheostomy dressing once a day

A

What nursing action will limit hypoxia when suctioning a client's airway? A apply suction only after catheter is inserted B limit suctioning with catheter to half a minute C Lubricate the catheter with saline before insertion D Use a sterile suction catheter for each suctioning episode

A

Which complication is the result of constant pressure exerted by a tracheostomy cuff causing tracheal dilation and erosion of cartilage? A Tracheomalacia B Tracheal stenosis C Tracheoesophageal fistula D Trachea-innominate artery fistula

A

A patient sustained a serious crush injury to the neck and had a trach tube placed 3 days ago. As the nurse is performing trach care, the patient suddenly sneezes forcefully and the tube falls out onto the bed linens. What does the nurse do? A ventilate the patient with 100% oxygen and notify the provider B quickly and gently replace the tube with a clean cannula kept at the bedside C quickly rinse the tube with sterile solution and gently replace it D Give the patient oxygen; call for assistance and a new tracheostomy kit

B

Patients with a tracheostomy or endotracheal tube need suctioning. Which nursing interventions apply to proper suctioning technique? Select all that apply A preoxygenate the patient for at least 30 seconds before suctioning B Instruct the patient that he or she is going to be suctioned C quickly insert the suction catheter until resistance is met D suction the patient for at least 30 seconds to remove secretions E repeat suctioning as needed for to five total suction passes

ABC

A patient was intubated for acute respiratory failure, and there is an endotracheal tube in place. Which nursing interventions are appropriate for this patient? Select all that apply. A ensure that the oxygen is warmed and humidified B suction the airway, then the mouth, and give oral care C Suction the airway with the oral suction equiptment D Position the tubing so it does not pull on the airway E apply suction only when withdrawing the suction catheter

ABDE

A patient with a trach who receives unnecessary suctioning can experience which complications? Select all that apply A bronchospasm B mucosal damage C impaired gag reflex D bronchodialation E bleeding

ABE

A patient has a recent tracheostomy. What necessary equipment does the nurse ensure is kept at the bedside? Select all that apply. A ambu bag B pair of wire cutters C oxygen tubing D suction equiptment E tracheostomy tube with obturator

ACDE

What are possible complications that can occur with suctioning from an artificial airway? Select all that apply A infection B coughing C hypoxia D tissue (mucosa) trauma E Vagal stimulation F bronchospasm

ACDEF

A patient with a trach tube is currently alert and cooperative but seems to be coughing more frequently and producing more secretions than usual. The nurse determines there is a need for suctioning. Which nursing intervention does the nurse use to prevent hypoxia for this patient? A. allow the patient to breathe room air prior to suctioning B avoid prolonged suctioning time C suction frequently when the patient is coughing D use the largest available catheter

B

A patient with a tracheostomy is unable to speak. He is not in acute distress, but is gesturing and trying to communicate with the nurse. Which nursing intervention is the best approach in this situation? A reply on the family to interpret for the patient B ask questions that can be answered with a yes or no response C obtain an immediate consult with the speech therapist D encourage the patient to rest rather than struggle with communication

B

To prevent accidental decannulation of a tracheostomy tube, what does the nurse do? A obtain an order for continuous upper extremity restraints B secure the tube in place using ties or fabric fastners C allow some flexibility in motion of the tube while coughing D instruct the patient to hold the tube with a tissue while coughing

B

Which nursing action is important when suctioning the secretions of a client with a tracheostomy? A. use a new sterile catheter with each insertion B initiate suction as the catheter is being withdrawn C insert the catheter until the cough reflex is stimulated D Remove the inner cannula before inserting the suction catheter

B

A patient returns from the OR after having a tracheostomy. While assessing the patient, which observations made by the nurse warrant immediate notification of the provider? A patient is alert but unable to speak and has difficulty communicating his needs B small amount of bleeding present at incision C skin is puffy at the neck area with a crackling sensation D respirations are audible and noisy with increased RR

C

A patient returns from the OR and the nurses assesses for subcutaneous emphysema, which is a potential complication associated with tracheostomy. How does the nurse assess for this complication? A checking the volume of the pilot baloon B listening for airflow through the tube C inspecting and palpating for air under the skin D assessing the tube for patency

C

A patient who is breathing on his own has a fenestrated trach tube with a cuff. Which precaution must the nurse instruct the student about when caring for this patient? A always keep the cuff inflated to prevent secretions from entering the lungs B suction the patient every 30 to 60 minutes C always deflate the cuff before capping the tube with the decannulation cuff D To reduce the risk for tracheal damage, keep the cuff pressure between 22 and 30 mm Hg

C

The nurse is suctioning the secretions from a patient's endotracheal tube. The patient demonstrates a vagal response by a drop in heart rate to 54/min and a drop in BP to 90/55 mm Hg. After stopping suctioning, what is the nurses priority action? A allow the patient to rest for at least 10 mins B monitor the patient and call the Rapid Response team C oxygenate with 100% oxygen and monitor the patient D administer atropine according to standing orders

C

Which clinical finding in a patient with a recent tracheostomy is the most serious and requires immediate intervention? A increased cough and difficulty expectorating secretions B food particles in the tracheal secretions C pulsating tracheostomy tube in synchrony with the heartbeat D set tidal volume on the ventilator not being received by the patient

C

You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to intervene? A suctioning the trach tube before performing trach care B removing old dressings and cleaning off excess secretions C removing the inner cannula and cleaning using standard precautions D replacing the inner cannula and cleaning the stoma site

C

While the nursing student changes a patients trach dressing, the nurse observes the student using a pair of scissors to cut a 4X4 gauze pad to make a split dressing that will fit around the trach tube. What is the nurses best action? A give the student positive reinforcement for use of materials and technique B report the student to the instructor for remediation of the skill C change the dressing immediately after the student has left the room D direct the student in the correct use of materials and explain the rationale

D

a patient has a cuffed trach tube without a pressure relief valve. To prevent tissue damage of the tracheal mucosa, what does the nurse do? A deflate the cuff every 2 to 4 hours and maintain as needed B change the tracheostomy tube every 3 days or per hospital policy C assess and record cuff pressure each shift using the occlusive technique D assess and record cuff pressure each shift using minimal leak technique

D

A patient with a tracheostomy without a tube in place develops increased coughing, inability to expectorate secretions, and difficulty breathing. What are these assessment findings related to? A overinflation of the pilot baloon B tracheoesophageal fistula C cuff leak and rupture D tracheal stenosis

D

A patient with a permanent trach is interested in developing an exercise regime. Which activity does the nurse advise the patient to avoid? A aerobics B Tennis C golf D swimming

D

A patient with a trach is being discharged to home. In patient teaching, what does the nurse instruct the patient to do? A use sterile technique when suctioning B instill tap water into the artificial airway C clean the trach tube with soap and water D Increase the humidity in the home

D