Skills 2 Module 8

The student nurse is observing the staff nurse perform routine tracheostomy care. Which of the following actions, if made by the staff nurse, would be inappropriate? A) The nurse removes the soiled tracheostomy ties, cleans the flange, and applies new tracheostomy ties, securing them tightly behind the patient's neck. B) The nurse oxygenates the patient, suctions the tracheostomy tube, and removes the soiled tracheostomy dressing before removing gloves. C) The nurse cleans around the tracheostomy faceplate and stoma with hydrogen peroxide, then rinses with normal saline-saturated gauze and cotton-tipped applicators. D) The nurse removes the inner cannula and places it in a sterile basin of hydrogen peroxide to soak.

A) The nurse removes the soiled tracheostomy ties, cleans the flange, and applies new tracheostomy ties, securing them tightly behind the patient's neck.

The nurse is orienting a newly hired nurse to a surgical intensive care unit. The newly hired nurse asks when endotracheal tube care is necessary. The correct response is: A) "Signs that endotracheal tube care must be performed include loosening of the tapes, soiled tapes, mobility of the tube, and alteration in skin or tissue integrity." B) "When the patient begins to cough continuously." C) "It should be done at least every 8 to 12 hours." D) "Indications for endotracheal tube care include wheezes, crackles, audible gurgling, secretions in the mouth, decreased pulse oximetry, tachypnea, and tachycardia."

A) "Signs that endotracheal tube care must be performed include loosening of the tapes, soiled tapes, mobility of the tube, and alteration in skin or tissue integrity."

The patient's wife asks why the nurse turns the oxygen all the way up before suctioning the patient. The nurse's best response is: A) "It is necessary in order to create the pressure needed to make the suction machine work effectively." B) "Because suctioning will remove oxygen, the flow rate is increased to prevent a decrease in oxygen available to tissues." C) "As secretions are removed, they need to be replaced with oxygen." D) "A high concentration of oxygen stimulates the respiratory center so the patient will continue breathing during the suctioning procedure."

B) "Because suctioning will remove oxygen, the flow rate is increased to prevent a decrease in oxygen available to tissues."

What is the purpose of having a fenestrated tube in an artificial airway? A) To decrease the likelihood of aspiration of stomach contents. B) To allow a patient to talk. C) To prevent dislodgment. D) To prevent trauma to the trachea.

B) To allow a patient to talk.

Which task could be delegated to NAP? A) Nasotracheal suctioning. B) Tracheostomy care of a well-established tracheostomy. C) Closed inline suctioning if a patient is on a mechanical ventilator. D) Endotracheal tube care.

B) Tracheostomy care of a well-established tracheostomy.

A nurse is trying to determine whether or not a patient's artificial airway should be suctioned. Which of the following fails to be an indication for suctioning? A) Pulse oximetry 89%. B) Pulmonary secretions. C) 2 hours have elapsed since patient was last suctioned. D) Patient has audible gurgling and appears restless.

C) 2 hours have elapsed since patient was last suctioned.

For the patient who extubated himself, what is the priority action the nurse should take? A) Apply a sterile dressing to the site. B) Notify the physician. C) Determine whether the patient is breathing spontaneously. D) Medicate the patient for pain and assess for tissue damage.

C) Determine whether the patient is breathing spontaneously.

The nurse is preparing to perform nasotracheal suctioning on a patient. Which of the following would be an appropriate nursing action? A) To effectively suction the left main stem bronchus, turn the patient's head to the left. B) When suctioning artificial airways, it is important to apply suction during insertion. C) Hyperoxygenate the patient prior to suctioning and allow 1 to 2 minutes between suction passes. D) For open nasotracheal suctioning, clean gloves are appropriate.

C) Hyperoxygenate the patient prior to suctioning and allow 1 to 2 minutes between suction passes.

A middle-aged woman has been hospitalized for a left lower lobectomy for treatment of lung cancer. She has now recovered enough to be sent home. To assist her in continuing to recover, you review various coughing techniques with her. A. Cascade B. Huff C. Quad The patient inhales, taking a deep breath and holding it for 2 seconds and performs a series of coughs throughout exhalation. Used when the patient becomes stronger and has a greater cough effort; good for patients with large amounts of sputum. Used with patients who have spinal cord injuries. Stimulates a natural cough reflex; effective for clearing central airways. When the patient exhales, you push on the abdominal muscles toward the diaphragm, causing the patient to cough.

Cascade :The patient inhales, taking a deep breath and holding it for 2 seconds and performs a series of coughs throughout exhalation. , Cascade :Used when the patient becomes stronger and has a greater cough effort; good for patients with large amounts of sputum. , Quad :Used with patients who have spinal cord injuries. , Huff :Stimulates a natural cough reflex; effective for clearing central airways. , Quad :When the patient exhales, you push on the abdominal muscles toward the diaphragm, causing the patient to cough.

The nurse is going to perform inline tracheostomy suctioning followed by tracheostomy tube care (using a disposable inner cannula). Which of the following is an incorrect step in the sequence for these procedures? A) Perform hand hygiene. Connect the suctioning tubing to the suction machine. Set on low. Hyperoxygenate the patient. Unlock the suction catheter. Insert the catheter during inspiration. B) Apply suction. Withdraw the catheter to the point indicated. Lock the suction catheter. Turn off the suction machine. Provide oral care. C) Remove existing tracheostomy dressing. Using sterile technique, open the tracheostomy kit. Prepare the supplies: open 4-by-4 gauze, saline, and hydrogen peroxide. Place cotton swabs in saline solution. D) Apply clean gloves. Remove the existing inner cannula. Insert the new inner cannula. Clean around the stoma and flange. Have another family member hold the tracheostomy tube. E) Cut the existing tracheostomy ties and remove them. Install new tracheostomy ties. Insert new tracheostomy dressing. Discard the used equipment and supplies. Reposition the patient.

D) Apply clean gloves. Remove the existing inner cannula. Insert the new inner cannula. Clean around the stoma and flange. Have another family member hold the tracheostomy tube.

Which step in the sequence of nasopharyngeal suctioning requires correction? A) Perform hand hygiene. Connect suctioning tubing to the suction machine and turn it on. Have supplemental oxygen available. B) Maintaining sterile technique, open suction catheter. Fill the basin with 100 mL of sterile saline/water. Open the package of water-soluble lubricant. C) Apply sterile gloves. Attach suction catheter to connecting tubing. Test the assembled suctioning equipment. D) Lubricate the end of the catheter. Insert the catheter during expiration. Apply continuous suction for approximately 1 minute as the catheter is withdrawn.

D) Lubricate the end of the catheter. Insert the catheter during expiration. Apply continuous suction for approximately 1 minute as the catheter is withdrawn.

The nurse is performing endotracheal tube care. Which step is an appropriate nursing action for performing this skill? A) Fold the tape that holds the endotracheal tube in place lengthwise to prevent it from sticking to the patient's head/hair. B) Use the tongue blades to inspect the patient's oral cavity for sores. C) Rotate the endotracheal tube to the opposite side of the mouth only if a lesion has developed under the tube. D) Use two people to carry out the procedure.

D) Use two people to carry out the procedure.

A patient with a weak cough has secretions in the lower airway. What would be an appropriate response by the nurse? A) Oropharyngeal suctioning. B) Nasopharyngeal suctioning. C) Nasotracheal suctioning. D) Quad cough.

Nasotracheal suctioning.

Which suctioning techniques can be delegated to trained and competent NAP and/or patients and their families when the patient is stable? (Select all that apply.) A) Oropharyngeal. B) Nasotracheal. C) Open tracheostomy. D) Open endotracheal. E) Inline endotracheal.

Oropharyngeal suctioning may be delegated to appropriately trained NAP. It is inappropriate to delegate nasotracheal and endotracheal tube suctioning to NAP. The skill of performing tracheostomy tube suctioning can be delegated to NAP or the patient/family who are trained in the procedure when the tracheostomy is well-established. AC

A patient has clear oral secretions that are extremely copious and thick. What would be an appropriate response by the nurse? A) Oropharyngeal suctioning. B) Nasopharyngeal suctioning. C) Nasotracheal suctioning. D) Obtain a sputum specimen for culture and sensitivity.

Oropharyngeal suctioning.

The nurse is concerned the patient is developing atelectasis as a result of immobility. Crackles are noted upon auscultation. Which type of coughing technique is best for the nurse to teach the patient? A) Cascade. B) Huff. C) Quad. D) Chest percussion.

Oropharyngeal suctioning.

Choose the symptoms that indicate the need to suction a tracheostomy tube: (Select all that apply.) A) Sonorous wheezing. B) Gurgling. C) Restless/anxious. D) Cyanosis. E) Mucus draining from the tracheostomy tube. F) Pulse oximetry value below 90%. G) Fatigue. H) Posturing.

Signs and symptoms that indicate that a tracheostomy may need suctioning include coughing, wheezes, gurgling, crackles on inspiration and/or expiration, restlessness/anxiety, cyanosis, mucus draining from the tracheostomy tube, and pulse oximetry values below 90%. Suctioning would further increase fatigue. Posturing may be seen with brain injury. ABCDEF

After the NAP performs routine vital signs on the patient, the NAP reports to the nurse that the patient is restless, and it sounds like the patient is gurgling. Vital sign readings indicate a pulse of 72, respiratory rate of 20 breaths per minute, and a pulse oximetry of 89%. What is the most appropriate action at this time? A) Document the normal findings. B) Consult with the physician regarding need for a bronchodilator. C) Suction the patient's airway. D) Have the patient take a deep breath and reassess pulse oximetry.

Suction the patient's airway.

The nurse is performing closed inline suctioning. Pre-procedure assessment indicated crackles and wheezes bilaterally, pulse rate 72, respiratory rate 20 breaths per minute, and pulse oximetry 89%. Which of the following indicates the nurse should stop suctioning and administer oxygen? A) The patient's respiratory rate remains unchanged. B) The patient's pulse oximetry increases to 94%. C) Thick clear sputum is obtained during suctioning. D) The patient's pulse increases to 114 beats per minute.

The patient's pulse increases to 114 beats per minute.