Trach care EAQ
When the nurse educator is observing a student performing tracheal suctioning of a client with thick secretions, which student action requires intervention? A. Maintains a sterile field B. Applies suction during insertion of the catheter C. Preoxygenates with 100% oxygen for 1 minute D. Tests suction pressure at 100 mm Hg before inserting catheter
B. Applies suction during insertion of the catheter
The nurse is suctioning a client's airway. Which nursing action will limit hypoxia? A. Limit suctioning with catheter to 30 seconds B. Apply suction only after the catheter is inserted C. Lubricate the catheter with saline before insertion D. Use a sterile suction catheter for each suctioning episode
B. Apply suction only after the catheter is inserted
Which nursing action is appropriate when suctioning the secretions of a client with a trach? A. Use a new sterile catheter with each insertion B. Initiate suction as the catheter is being withdrawn C. Insert the catheter until the cough reflex is stimulated D. remove the inner cannula before inserting the suction catheter
B. Initiate suction as the catheter is being withdrawn
A client has a trach tube attached to a trach collar for the delivery of humidified oxygen. What is the primary reason that suctioning is included in the client's plan of care? A. Humidified oxygen is saturated with fluid B. The trach tube interfered with effective coughing C. The inner cannula of the trach tube irritates the mucosa D. The weaning process increases the amount of respiratory secretions
B. The trach tube interfered with effective coughing
To prevent potential aspiration, which technique would the nurse use when cleaning a trach tube that has a nondisposable inner cannula? A. Apply precut dressing around the insertion site with the flaps pointing upward B. Replace the tube with a sterile obturator C. Use sterile cotton balls to cleans the outer cannula D. Remove the cannula after the high-volume, low-pressure cuff has been deflated
A. Apply precut dressing around the insertion site with the flaps pointing upward
When the nurse is assessing a client after trach placement, which finding requires immediate action by the nurse? A. Crackling of the skin on palpation B. Small amount of blood at the surgical site C. Client reports the area around incision is tender D. The client is unable to speak with a cuffed tube
A. Crackling of the skin on palpation
A client develops acute respiratory distress, and a tracheostomy is performed. Which of the following interventions is most important for the nurse to implement when caring for this client? A. Encouraging a fluid intake of 3 L daily B. Suctioning via the tracheostomy every hour C. Applying an occlusive dressing over the surgical site D. using cotton balls to cleans the stoma with peroxide
A. Encouraging a fluid intake of 3 L daily
The nurse is caring for a client with a trach. Which action would the nurse implement when performing tracheal suctioning? A. Preoxygenate the client before suctioning B. Employ gentle suctioning as the catheter is being inserted C. Loosen the client's secretions before suctioning by instilling saline D. Ensure that the cuff of the tracheostomy is inflated during suctioning
A. Preoxygenate the client before suctioning
A post-op patient with a trach in place suddenly develops noisy, increased respirations and an elevated heart rate. The nurse would take which action immediately? A. Suction the trach B. change the trach tube C. Readjust the trach tube and tighten the ties D. Perform a complete respiratory assessment
A. Suction the trach
A client has a trach tube with a high-volume, low-pressure cuff. The nurse understands that type of cuff is designed to prevent which occurrence? A. Any leakage of air B. Lung infection C. Mucosal necrosis D. Tracheal secretions
C. Mucosal necrosis
The RN is delegating care for a client who underwent a tracheostomy. Which task could be delegated to the licensed practical nurse (LPN? A. Developing a plan to avoid aspiration B. Assessing the client's condition after tracheostomy C. Providing tracheostomy care using sterile techniques D. Teaching a client and caregiver about home tracheostomy care
C. Providing tracheostomy care using sterile techniques
Which action will the nurse take to support safe oral intake after tracheostomy? A. Include thin liquids B. Provide large meals C. Inflate the tracheostomy cuff fully D. Position client as upright as possible
D. Position client as upright as possible
Which finding in a client who has home oxygen therapy with a trach collar requires immediate action by the home health nurse? A. Condensation in the tubing B. Oxygen flow rate 9 L/min C. Low fluid level in the humidifier D. Scented candle burning in the room
D. Scented candle burning in the room