Tracheostomy Care Quiz Q's

The nurse is preparing to suction a clients trach following cardiac surgery. To help minimize the clients anxiety, which statement made by the nurse is the most therapeutic?

- "if you experience any difficulty, squeeze my hand and i will stop to allow you to rest."

The nurse is preparing to suction a client's trach. The nurse would place which client in the lateral position facing the nurse?

- The unconscious client, after abdominal surgery

After assessing clients with a trach, which client will the nurse suction?

- a client with rhonchi in upper airways

When providing trach care to a client with a disposable inner cannula, at which point would the nurse put on sterile gloves?

- after removing the old inner cannula

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

- apply suction at 110-130mmHg from the wall unit

The nurse is preparing to provide trach care to a client with a new trach. Which action should the nurse take before beginning the procedure?

- assess the client for pain and administer the analgesic as needed

The nurse just finished suctioning a client with a trach. Which action should the nurse take next?

- assess the lung sounds

Which client is most likely to need administration of pain meds prior to being suctioned via the tracheostomy?

- client who had abdominal surgery

After changing the disposable inner cannula and changing the dressing of a client who has a trach, the nurse prepares to change the clients trach collar. What action would the nurse take first?-

- enlist the help of a 2nd nurse

The nurse is preparing to change a clients trach collar. Which action is most appropriate?

- enlist the help of a second nurse to hold the trach tube in place while the old collar is removed and the new collar is placed

The nurse just finished replacing a disposable inner cannula of a client's trach. The client is coughing a dislodges the trach. Which action should the nurse take first?

- insert the obturator into a new trach and insert the trach into the stoma

The nurse has assessed a client with a trach and decided suctioning was needed. Which action will the nurse implement to help prevent complications?

- limit suctioning passes to no more than three per episode

When suctioning a client with a trach using an open system, which actions by the nurse would help to prevent hypoxemia during the procedure?

- limit suctioning to 10-15 seconds - hyperventilate the client before suctioning - pause for 30 to 60 seconds between suctioning attempts

The nurse is suctioning a clients trach using an open system. For which action should the nurse use the gloved, dominant hand?

- manipulating the suction catheter

On assessment, the nurse notes secretions on the clients trach dressing. The health care provider's prescription states that trach site care be done once per shift. The nurse has already performed site care once during the shift. What is the best action by the nurse?

- perform site care again and document procedure

The nurse is providing trach care for a client and cleans the non-disposable inner cannula with the brush. What step is next?

- place the inner cannula in a basin of sterile saline

The nurse is providing tach care to a client with a non-disposable inner cannula. Which action should the nurse take next after removing the inner cannula?

- replace the clients o2 source over the outer cannula

On assessment, the nurse notes that the trach ties are grossly soiled adn require changing. No one is available to assist at this time. What is the best action by the nurse?

- secure the new trach before removing old ties

When should the nurse suction the oral cavity?

- shortly after suctioning the trach

The nurse is providing site care for a client with a trach using a non-disposable inner cannula. Which step is recommended to release the lock on the device?

- stabilize the outer cannula and faceplate with the non-dominant hand

While providing care to a client who has a trach with a non-disposable inner cannula, the nurse observes secretions that have accumulated on the outer cannula. Which action would the nurse take?

- suction the outer cannula using aseptic technique

After changing the clients trach holder, the nurse determines that the collar fits properly when:

- the client can flex the neck comfortably

The nurse observes the family caregiver doing trach care for a client with a non-disposable inner cannula. Which action by the family caregiver indicates additional teaching is needed?

- the family caregiver rotates the inner cannula clockwise with the non-dominant hand to release the lock

The nurse is providing tach care for a client. When changing the dressing, which action would be most appropriate for cleaning the stoma?

- use each applicator only once, moving from the stoma site outwards

The nurse is preparing to provide trach care to a client. The client's trach dressing is soiled, but a commercially prepared teach dressing is not available. Which action should the nurse take?

- use two folded gauze sponges on each side of the stoma

The nurse is observing a student nurse suction a client with a trach using an open system. Which action by the student requires additional instruction?

- uses a manual resuscitation bag to give the client 2big breaths before beginning.

When preparing to suction a client's trach, which action by the nurse best helps to prevent the introduction of microorganisms into the respiratory tract?

- using only the dominant hand to handle and manipulate the catheter.

The nurse is inserting the suction catheter into a client's trach and suddenly meets resistance. What action would be most appropriate by the nurse?

- withdraw the catheter at least 0.5in

While suctioning a client, the nurse inserts a closed system suction catheter into the trach tube and meets resistance. Which action should the nurse take?

- withdraw the catheter at least 0.5in before applying suction