Tracheostomy Care
Which nursing action is appropriate when suctioning the secretions of a client with a tracheostomy?
Initiate suction as the catheter is being withdrawn.
The nurse instructs a client to breathe deeply to open collapsed alveoli. Which explanation could the nurse offer to explain the relationship between alveoli and improved oxygenation?
"Oxygen is exchanged for carbon dioxide in the alveolar membrane."
After a laryngectomy is scheduled, which is the most important factor for the nurse to include in the preoperative teaching plan?
Establishing a means for communicating postoperatively
A client has a tracheostomy tube with a high-volume, low-pressure cuff. The nurse understands that type of cuff is designed to prevent which occurrence?
Mucosal necrosis
The nurse is caring for a client whose mechanical ventilator settings include the use of positive end-expiratory pressure (PEEP). This treatment improves oxygenation primarily through which mechanism of action?
Opening collapsed alveoli and keeping them open
A client develops subcutaneous emphysema after the surgical creation of a tracheostomy. Which assessment by the nurse most readily detects this complication?
Palpating the neck or face
Which action will the nurse take to support safe oral intake after tracheostomy?
Position client as upright as possible.
The nurse is caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. The plan of care for the tube would include which nursing intervention?
Verify that a low-pressure cuff is in place.
When the nurse educator is observing a student performing tracheal suctioning of a client with thick secretions, which student action requires intervention?
Applies suction during insertion of the catheter
Which action by the nurse would best facilitate communication for a client with a partial laryngectomy and tracheostomy in the immediate postoperative period?
Provide a means for the client to write.
The nurse is suctioning a client's tracheostomy. What is the correct order of nursing actions when performing this procedure?
1. Auscultate the lungs and check the heart rate. 2. Prepare by turning suction on to between 80 and 120 mm Hg pressure. 3. Hyper oxygenate using 100% oxygen. 4. Don sterile gloves. 5. Guide the catheter into the tracheostomy tube using a sterile-gloved hand.
The nurse is suctioning a client's airway. Which nursing action will limit hypoxia?
A. Apply suction only after catheter is inserted
When the nurse is assessing a client after tracheostomy placement, which finding requires immediate action by the nurse?
Crackling sensation around the neck when skin is palpated.
A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client?
Encouraging a fluid intake of 3 L daily
A client is admitted with multiple injuries as a result of an accident. A tracheostomy was performed. While the nurse is caring for this client, the client coughs, expelling the tracheostomy tube onto the bed. Which action would the nurse take?
Hold the tracheostomy open with a tracheal dilator and call for assistance.
The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning?
Preoxygenate the client before suctioning.
A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason that suctioning is included in the client's plan of care?
The tracheostomy tube interferes with effective coughing.
How would the nurse position a client to practice supraglottic swallowing after tracheostomy?
Upright
Which actions will the nurse include when doing tracheostomy care? Select all that apply. One, some, or all responses may be correct.
Use sterile technique when cleaning the inner cannula. Don sterile gloves before removing the inner cannula.
