Suctioning and Tracheostomy
How long should a suction procedure last?
Approximately 15 seconds
The client who is concerned about getting a tracheostomy says, "I will be ugly, with a hole in my neck." What is the nurse's best response?
"Do you have a light scarf that you could place over it?"
The client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about tracheostomy care?
"I can only take baths, no showers."
Which of the following statements best explains the use of pain medication in the postoperative period
"The medication will decrease the pain perception but will allow the client to deep breathe and cough
The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?
10 seconds
What is the recommended pressure setting for the suction unit?
120 mmHg
The client tells the nurse during the preoperative history that he is a three-pack a day cigarette smoker. This information alerts the nurse to which of the following potential complication during the intraoperative and postoperative periods?
An increased risk for atelectasis and hypoxia
All of the members of the surgical team must perform a "surgical scrub" except for which of the following person?
Anesthetist / Anesthesiologist
A client with a tracheostomy is at increased risk for aspiration. Which nursing intervention(s) will reduce this risk? SELECT ALL THAT APPLY.
ALL OF THE ABOVE
In the operating room, prior to the induction of anesthesia, the client tells the circulating nurse that he is going to have the cataract in his left eye removed. The nurse notes that the consent form indicates that surgery is to be performed on the right eye. Which of the following is the best first action by the nurse?
Ask the client his name.
Which of the following action or statement is most likely to reduce anxiety in a client being brought to the surgical suite?
Asking the client if he or she wants family members to be with them in the holding area.
When caring for a client with a tracheostomy, the nurse would perform which recommended action?
Assess a newly inserted tracheostomy every 3 to 4 hours.
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist?
Assess the ability to swallow before using the fenestrated tube.
Which of the following complications can result from the use of general anesthesia during surgery?
Atelectasis
Following a laryngectomy a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?
Attempt to reinsert the tracheostomy tube with the obturator in place.
On admission to the preoperative area, the client who is scheduled for a hip replacement tells the nurse that she has made three autologous blood donations for this surgery in the past 5 weeks. Which of the following is best action by the nurse?
Call the laboratory to ensure that the blood is physically available at the operating room facility
Twenty minutes after the client has received a preoperative injection of atropine and midazolam (Versed), The client tells the nurse that he must be allergic to the medication because his mouth is dry and his heart seemed to be beating faster than normal. Which of the following is the best first action by the nurse?
Check the client's pulse and blood pressure
A new graduate RN discovers that her client, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first?
Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask
While examining the 82 - year-old client's preoperative laboratory blood tests, the nurse finds the client's serum sodium level to be 139mEq/ml. Which of the following is best action by the nurse?
Document the finding as the only action
The client is undergoing an induction of anesthesia with succinylcholine, a depolarizing blocker agent, begins to experience generalized muscle twitching. Which of the following is the best response by the circulating nurse?
Document this expected response
The client is to undergo a gynecologic surgical procedure that requires the client to be in the lithotomy position. At which of the following point should the circulating nurse place the client in the lithotomy position?
During the stage 3 of general anesthesia to avoid overstimulating the client or disrupting the attainment of a patent airway
For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube?
Hyperoxygenate before and after suctioning
or client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube?
Hyperoxygenate before and after suctioning
After surgery from general anesthesia, how should the nurse instruct the client to deep breathe and cough? I. "Assume a sitting position." II. "Lie on your back." III. "Hold breathe and slowly exhale." IV. "Splint the surgical incision to minimize pain."
I, III, IV
Which of the following changes in the anesthetized client alerts the nurse to the possibility of malignant hyperthermia?
Increased end tidal carbon dioxide leveL
The client who is scheduled to have surgery cannot read or write. The surgeon obtaining the consent wants to have the client's spouse sign the consent instead. Which of the following is the best action by the nurse?
Inform the surgeon that the client may sign the informed consent statement with an X in front of two witnesses.
A client has just arrived in the PACU following a successful tracheostomy procedure. Which nursing action must be taken first?
Listen to lung sound
The stages of surgical anesthesia proceeds in which of the following order?
Loss of consciousness, excitement, surgical anesthesia, danger stage
The surgeon closes the client's abdominal tissue layer. The nurse knows that closure of the abdominal tissue layers begins with the peritoneum, extra peritoneal fat, transversalis fascia, followed by which of the following layers?
Muscle, deep fascia, subcutaneous tissue, skin
The client undergoing preoperative assessment before an elective procedure tells the nurse that she has been taking 10 mg of prednisone daily for rheumatoid arthritis. Which of the following is the best action by the nurse?
Notify the surgeon and anesthesiologist
When during the suction procedure should suction be applied?
Only when withdrawing the suction catheter.
How does palliative surgery differ from any other type of surgery?
Palliative surgery is performed to provide temporary relief of distressing symptoms rather than to cure a problem or condition.
The older adult client with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this client during the postoperative period?
Picture board
A nurse who is caring for patient with a tracheostomy tube in place has just auscultated rhonchi bilaterally. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?
Put on sterile gloves and use a sterile catheter to suction.
Which of the following are possible indications for performing suction?
Reduced oxygen saturation level
The client with a new tracheostomy has a soiled dressing. What is the best nursing intervention?
Replace the dressing with sterile, folded 4 x 4 gauze
Which of the following is the best technique to use when rinsing hands and forearms after surgical scrub?
Rinsing should start with the hand positioned so that water runs off the extremity rather than up or down.
Which of the following task or function during a surgical procedure is designated as being within the scope of practice for the scrub nurse?
Setting up the sterile field
What is the most appropriate nursing intervention if your client's heart rate drops during suctioning?
Stop and deoxygenate the patient
Surgical closure of the skin surfaces usually involves the use of which of the following type of needle?
Straight needle
Respirations of the sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse?
Suction the client
When caring for a client with a tracheostomy, the nurse would perform which recommended action?
Suction the tracheostomy tube using sterile technique.
One of the function of the recovery room nurse is to monitor the client level of consciousness after surgery. Which of the following findings the nurse must reports to the physician?
Systolic blood pressure drops from 130 to 100 mmHg
In which of the following situation is the nurse performing the role of client advocate during the preoperative period?
Teaching the client how to perform coughing and deep breathing exercises
When the nurse brings the preoperative medication to the client about to have abdominal surgery, she tells the nurse that she does not need the injection because she had a good night's sleep last night. Which of the following is the nurse best first action?
Tell the client that the preoperative medication is ordered to reduce the risk of some problems during surgery rather than to ensure adequate rest
Which one of the following is a contraindication for inserting a nasopharyngeal airway?
The client has a fractured base of skull.
The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse, if noted by the charge nurse, would cause the charge nurse to intervene?
The newly hired nurse delegates care of the tracheostomy to a student nurse.
To facilitate drainage of secretions from the operative site, which of the following interventions the nurse should employ?
Turn the client to the operative side every 2-3 hours
The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated?
Use a manometer to ensure cuff pressure is at an appropriate level.
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?
opening in the trachea that enables breathing
A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?
trauma to the tracheal mucosa
