Tracheostomy Care, ATI skills- airway management
bronchus
one of the larger passageways conveying air to and within the pulmonary system
bronchiole
one of the subdivisions of the branched bronchial tree of the pulmonary system
When a patient's airway is at risk for obstruction or becomes obstructed, an artificial airway is inserted to maintain airway patency. Some common devices used for this purpose are?
oropharyngeal airways, nasopharyngeal airways, endotracheal tubes, and tracheostomy tubes.
Common types of suctioning?
oropharyngeal and nasopharyngeal suctioning, nasotracheal suctioning, and suctioning through an artificial airway.
cuff
referring to a tracheostomy, a cuff is a soft, inflatable balloon encircling the distal end of a tracheostomy tube
trachea
the cartilaginous and membranous tube that descends from the larynx and branches into the right and left main bronchi
intubation
the insertion of a tube into a body canal or cavity, as in endotracheal intubation
oropharynx
the part of the pharynx between the soft palate and the upper edge of the epiglottis
nasopharynx
the portion of the pharynx (the passage between the mouth and posterior nares and the larynx and esophagus) that lies above the level of the soft palate
pharynx
the throat; the cavity between the nasal passages and the mouth
When performing nasotracheal suctioning, it is important to?
use surgical asepsis (sterile technique) because the trachea is considered sterile. If a patient requires suctioning of both the trachea and mouth or oropharynx, suction the mouth last since it is considered clean, not sterile. In addition to gloves, be sure to wear other personal protective equipment (PPE), such as goggles or a face shield.
nasal trumpet
tube inserted through the nose and the pharynx to establish and maintain airway patency; also called a nasopharyngeal airway
When should you discontinue tracheal suctioning? (Select all that apply.) a. Heart rate decreases from baseline by 20 bpm b. Heart rate increases from baseline by 40 bpm c. Dysrhythmias occur d. SpO2 decreases to less than 90% e. Blood pressure drops by 20 mm Hg
a, b, c, d
atelectasis
airlessness or collapse of a lung, usually as a result of hypoventilation or obstruction
Endotracheal tube
-Endotracheal tubes are used for patients undergoing a procedure that requires general anesthesia and/or mechanical ventilation. -They are inserted either through the nose or the mouth past the epiglottis and vocal cords into the trachea and down to where the trachea bifurcates into the bronchi. -ET tubes are not usually left in place for more than 14 days as doing so places the patient at risk for infection and airway injury. -Endotracheal tubes are made of a flexible plastic material and are available in a variety of sizes. -The size used depends on the age and size of the patient. For adult patients, the ET tube will usually have a cuff that is inflated with air after insertion to prevent air from leaking around the tube and to prevent oral and gastric secretions from being aspirated.
nasopharyngeal airway
-Nasopharyngeal airways, sometimes called nasal trumpets, are also used to keep the upper airway patent. -They are inserted through the nares and extend into the oropharynx. -Because this type of airway does not stimulate the gag reflex, it can be used for patients who are alert. -The nasal airway is composed of a soft, flexible rubber material and is available in a variety of sizes. -To determine appropriate size for the patient, the airway is measured from the patient's nose to the angle of the jaw.
Oropharyngeal airway
-Oral airways are used to keep the upper airway patent when it is at risk for becoming obstructed by the tongue or by secretions. -Because this type of airway stimulates the gag reflex, it should be used only for patients whose level of consciousness is altered. -Oropharyngeal airways are made of hard plastic and are available in a variety of sizes. -To determine the correct size for a patient, measure the oropharyngeal airway from the corner of the patient's mouth to the angle of the jaw. -When inserting an oral airway, the curved end should initially point toward the cheek and be placed over the tongue. -Once it reaches the back of the mouth, it is rotated so that the curved part points down and follows the natural curve of the tongue. -The outer flange of the airway should be just outside the patient's lips.
Tracheostomy tube
-Tracheostomy tubes are used for long-term airway support. -They are inserted through a small opening in the neck into the trachea. -This type of airway may be permanent or temporary depending on the patient's condition and reason for the tracheostomy. -Tracheostomy tubes are made of either plastic or metal and are available in a variety of sizes. -Because metal tracheostomy tubes are temperature-sensitive, they must be protected from heat and cold to prevent tissue injury. Like ET tubes, tracheostomy tubes may have a cuff that is inflated with air after insertion. - Most tracheostomy tubes have an inner cannula that is temporarily removed during tracheostomy care. -a tracheostomy tube is the ONLY one whose placement requires a surgical procedure. -Postoperatively, the nursing priority is maintaining a patent airway. Tube obstruction is a major complication, as is tube dislodgement during the first 72 hours postoperatively. -It is essential to keep a manual resuscitation bag, a tracheostomy tube of the same size and type, a tracheostomy insertion tray, and an obturator at the patient's bedside. If the tracheostomy tube becomes dislodged, exert minimal pressure onto the tube to ease the tube back into place and then re-secure the tube by adjusting the ties to reduce movement of the tube. -Some other possible complications are pneumothorax, subcutaneous emphysema, hemorrhage (although small amounts of blood are to be expected), and infection, manifested by purulent drainage, erythema, pain, and edema.
Which of the following are indications for a tracheostomy? (Select all that apply) a. Bypass an upper airway obstruction b. Facilitate removal of secretions c. Permit long-term mechanical ventilation d. Correct respiratory abnormalities e. Allow respiratory tissue to heal after chronic cigarette use f. Permit oral intake and speech in those whom require long term mechanical ventilation
a, b, c, f
A nurse is performing chest physiotherapy for a patient who needs help mobilizing and expectorating thick pulmonary secretions. To increase the turbulence of the air the patient exhales, the nurse should use which of the following techniques? a. vibration b. percussion c. nebulization d. postural drainage
A- vibration Vibration is used during or after percussion to increase the turbulence of exhaled air and loosen secretions.
What is the minimal leak technique?
An alternative approach that involves inflating the cuff with the minimum amount of air to obtain a seal, and then withdrawing 0.1 mL of air
Which of the following are complications that result from excessive tracheal or oropharyngeal suctioning? (Select all that apply) a. Bradycardia b. Nonproductive cough c. Arrhythmias d. Hypotension e. Emesis
a, c, d
respiratory distress
in general, difficulty breathing, which can include any aspect of respiration: ventilation, perfusion, or gas exchange, for example
a nurse is suctioning a pt's airway using in-line suctioning. when using this method, it is appropriate for the nurse to a-hyperoxygenate the pt before disconnecting the ventilator b- apply suction pressure while advancing the catheter c-wear a face shield during the procedure d-reuse the catheter repeatedly
D- reuse the catheter repeatedly With in-line suctioning, the catheter attaches to the ventilator tubing and does not have to be replaced. It can be used repeatedly.
a nurse is caring for a pt who sustained trauma to his head and neck and will require long-term airway support. wotf devices will be required for home health care for this pt? a- nasopharyngeal airway b- oropharyngeal airway c- endotracheal tube d- tracheostomy tube
D- tracheostomy tube tracheostomy tubes are used for long-term airway support. They are suitable devices for long-term management of airway obstruction.
True/False: Patients with a cuffed tracheostomy tube can eat normally because the tracheal cuff protects against aspiration
False: Patients must first be changed to a cuffless tracheostomy or have their cuff deflated before attempting swallowing
True/False: Cuff deflation trials assess the patient's ability to protect their airway and clear secretions
True
True/False: If a tracheostomy tube accidentally falls out, the stoma can be covered with a gloved hand while attempting to ventilate with a bag and mask.
True
True/False: Mucous that is not cleared from a lung can cause infections
True
vibration
a chest physiotherapy technique that involves applying pressure and a shaking movement of the hand to various areas over the lungs to mobilize pulmonary secretions
percussion
a chest physiotherapy technique that involves rhythmic clapping of cupped hands over various segments of the lungs to mobilize secretions
obturator
a device used to guide the outer portion of a tracheostomy tube during insertion and removed immediately after the outer tube is in place
hypoxemia
a diminished amount (reduced saturation) of oxygen in arterial blood
endotracheal (ET) tube
a hollow tube inserted in the trachea to establish and maintain a patent airway
nasotracheal tube
a hollow tube inserted through the nose into the trachea to establish and maintain a patent airway
suction catheter
a hollow, flexible tube passed into the airway to allow negative force to remove air, fluid, and secretions
postural drainage
a method of mobilizing pulmonary secretions by positioning the patient's head downward to incline the trachea below the affected area and facilitating removal of secretions by gravity; often used synonymously with chest physiotherapy, although that term technically refers to incorporating vibration and percussion techniques along with positioning
chest physiotherapy
a method of mobilizing pulmonary secretions by positioning the patient's head downward to incline the trachea below the affected area and then applying percussion and vibration techniques; often used synonymously with postural drainage, although that term technically refers to drainage by gravity without percussion and vibration
Yankauer suction tip
a plastic or metal tube with a curve at the distal end to facilitate the removal of thick secretions during suctioning; also called a tonsil tip suction catheter
hypoxia
a reduced supply of oxygen to tissues below physiological levels despite adequate perfusion of the tissue by blood
alveolus
a small, air-containing saclike dilation (outpouching) in the distal portions of the lungs where gases are exchanged with pulmonary capillary blood (plural: alveoli)
oropharyngeal airway
a tube inserted through the mouth and the pharynx to establish and maintain airway patency
Which of the following assessment data indicate that the patient's airway needs suctioning? (Select all that apply.) a. Drooling b. Production of thin, watery sputum c. Decreased coughing ability d. Secretions that clear with coughing e. Abnormal lung sounds only in the left lower lobe
a, b, c
a nurse is caring for a pt who has a cuffed endotracheal tube in place. wotf is an appropriate component of ET tube care for this pt? a- repositioning the ET tube in the pt's mouth Q8hrs b-providing oral and nasal care Q12hrs c- applying the securing tape over the pt's ears d- maintaining a cuff pressure of 30mm HG
a- repositioning the ET tube in the pt's mouth Q8hrs Moving the ET tube to the other side of the pt's mouth Q8hrs helps prevent irritation to the oral mucous membranes.
How can the nurse best minimize a patient's risk for infection during tracheostomy care? a. Adhere to sterile technique when appropriate. b. Frequently assess for signs of local or systemic infection. c. Monitor for indications that tracheostomy care is needed. d. Instruct nursing assistive personnel (NAP) to report any changes in color or odor of tracheal drainage.
a. Adhere to sterile technique when appropriate. Adherence to sterile technique is the most important factor in minimizing the patient's risk for infection during tracheostomy care.
Mucous is primarily produced in the lung by: a. Goblet cells b. Cilia c. Alveoli d. Lipid cells
a. Goblet cells
Which of the following is true regarding using hydrogen peroxide for tracheostomy dressing changes? a. Hydrogen peroxide should be diluted half strength with sterile saline b. Hydrogen peroxide should never be used c. Hydrogen peroxide can be used full strength to clean hard encrustrations from stoma d. Hydrogen peroxide should be used with every dressing change
a. Hydrogen peroxide should be diluted half strength with sterile saline
The nurse is caring for a patient who is recovering from a left partial lobectomy. Which action would be most helpful in re-expanding the affected lung? a. Placing the patient in a right side-lying position b. Encouraging the patient to deep breathe and cough every hour c. Regularly assessing the patient's ability to breathe comfortably d. Providing medication to manage postoperative pain of greater than 3 on a 0-to-10 scale
a. Placing the patient in a right side-lying position Placing the patient in a right side-lying position will facilitate re-expansion of the affected lung. The unaffected lung should be next to the bed, and the affected lung should be up.
Tracheostomy dressings should be changed: a. Q8H and PRN b. Q12H and PRN c. Q24H and PRN d. Q4HR and PRN
a. Q8H and PRN
A sterile technique is sometimes used to suction through an endotracheal or tracheostomy tube. A non-sterile technique is used to suction through a nasopharyngeal airway. This is because: a. When the suction catheter passes through the nasopharynx, it is already contaminated before it enters the trachea. b. A patient with an endotracheal or tracheostomy tube is immunocompromised c. There is a risk of the ETT or trach tube falling out during suctioning d. The patient has a better cough during tracheal suctioning of an ETT or trach tube
a. When the suction catheter passes through the nasopharynx, it is already contaminated before it enters the trachea.
hypercapnia
an excess of carbon dioxide in the blood
tracheostomy
an opening created by a surgical incision into the trachea for the purpose of establishing and maintaining a patent airway
artificial airway
any device inserted into the respiratory tract to facilitate breathing or secretion removal
Which of the following would be appropriate nursing diagnosis for someone with a Tracheostomy? (Select all that apply) a. Activity intolerance b. Ineffective airway clearance c. Impaired verbal communication d. Risk for ineffective relationship e. Risk for infection f. Risk for hypoxemia
b, c, e, f
A nurse is preparing to suction secretions from the mouth of a pt who has dysphagia. Which of the following is appropriate suction device or method for the nurse to use? a) in line suctioning b) Yankauer catheter c) bulb syringe d) open suctioning
b- yankauer catheter A Yankauer suction catheter helps clear secretions from the mouth.This is the appropriate device to use for pt's who can cough effectively but cannot swallow or expectorate secretions.
Apply negative pressure to the suction catheter inside the trachea as tolerated for a maximum of: a. 5 seconds b. 10 seconds c. 60 seconds d. 20 seconds
b. 10 seconds
Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? a. Cleaning the stoma with hydrogen peroxide and drying thoroughly b. Cleaning and assessing the skin around the stoma c. Assessing temperature and reporting skin breakdown immediately d. Allowing the patient to re-oxygenate after each tracheal suctioning
b. Cleaning and assessing the skin around the stoma Frequently cleaning and assessing the skin in the tracheostomy area will reduce the patient's risk for skin breakdown.
How does the nurse evaluate the effect of nasotracheal suctioning on a patient's respiratory status? a. Asking the patient about symptoms of respiratory difficulty b. Comparing respiratory assessment data from before and after the suctioning procedure. c. Confirming that the patient's pulse oximetry value is >90% d. Auscultating the patient's chest after suctioning
b. Comparing respiratory assessment data from before and after the suctioning procedure Comparing presuctioning and postsuctioning assessment data will provide the best measure of the procedure's efficacy.
Which nursing action related to the tracheostomy tube cuff pressure would prevent excessive pressure on tracheal capillaries? a. Monitor pressure every 2 to 3 days b. Ensure pressure is less than 20 mm Hg or 25 cm H2O c. Ensure pressure is less than 30 mm Hg or 35 cm H2O d. Ensure pressure is sufficient to fill the pilot balloon until it is tense
b. Ensure pressure is less than 20 mm Hg or 25 cm H2O
Which technique would the nurse use to change a patient's tracheostomy ties? a. Use a slipknot. b. Ensure that two fingers fit snugly under the tie. c. Knot the ends of the tie in the eyelets on the faceplate. d. Ask the patient to hold his or her breath while the ties are changed.
b. Ensure that two fingers fit snugly under the tie.
When would a tracheostomy tube with an inflated cuff be used? a. For patients with an altered level of consciousness b. For patients who are at risk of aspiration or need mechanical ventilation c. For patients who have a higher level of functioning d. All of the above
b. For patients who are at risk of aspiration or need mechanical ventilation
What would the nurse do first to ease breathing for a patient with mild dyspnea? a. Administer oxygen at 2 L/min by nasal cannula. b. Help the patient into an upright sitting position. c. Monitor the patient's pulse oximetry level. d. Determine if the patient has a history of respiratory pathology.
b. Help the patient into an upright sitting position. The nurse would first try to ease the patient's breathing using a noninvasive intervention such as this one. Placing the patient in a sitting position improves lung expansion.
Which nursing action shows the most effective planning for emergency care of a patient with a tracheostomy? a. Having a spare oxygen mask at the patient's bedside b. Keeping an obturator and a tracheostomy tube at the patient's bedside c. Reviewing the agency's policy regarding tracheostomy care d. Instructing the family to call immediately if the patient has difficulty breathing
b. Keeping an obturator and a tracheostomy tube at the patient's bedside Keeping an obturator and a tracheostomy tube of the correct size at the patient's bedside is the best way to plan for an emergency involving a tracheostomy, such as tube dislodgement.
During nasotracheal suctioning, the best indication your suction catheter has entered the trachea is: a. Patient will gag b. Patient will cough c. Patient will take a deep breath d. Green secretions are seen in suction catheter
b. Patient will cough
What is the function of an obturator? a. Communicates with the tracheal cuff to provide an indication of pressure b. Provides a smooth tip for easier insertion into the trachea c. Prevents the tube from being advanced too far into the trachea d. A removeable sleeve to facilitate cleaning
b. Provides a smooth tip for easier insertion into the trachea
As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and says, "I feel like I'm going to throw up." What is the nurse's best response? a. Complete the catheter insertion in 5 seconds or less. b. Remove the catheter. c. Encourage the patient to take several deep breaths to minimize the nausea. d. Stop advancing the catheter, and allow the patient to rest for several minutes.
b. Remove the catheter. Gagging and nausea indicate that the catheter has probably entered the esophagus and must be removed.
Which of the following tasks can the registered nurse (RN) delegate to an unregulated care provider (UCP) in the care of a stable patient who has a tracheostomy? a. Assessing the need for suctioning b. Suctioning the patient's oropharynx c. Assessing the patient's swallowing ability d. Maintaining appropriate cuff inflation pressure
b. Suctioning the patient's oropharynx Providing the individual has been trained in correct technique, the UCP may suction the patient's oropharynx. Assessing the need for suctioning should be performed by an RN or licensed practical nurse, whereas swallowing assessment and the maintenance of cuff inflation pressure should be performed solely by an RN.
Which of the following may be a cause for the formation of a tracheoesophageal fistula in a patient with a tracheostomy? a. Narrowing of tracheal lumen owing to scarring caused by tracheal irritation b. Tracheal wall necrosis leading to fistula formation c. Excessive manipulation or suctioning d. Air escapes from the incision to the subcutaneous tissue
b. Tracheal wall necrosis leading to fistula formation
When caring for a patient who is three hours postoperative laryngectomy, the nurse's highest priority assessment would be a. patient comfort. b. airway patency. c. incisional drainage. d. blood pressure and heart rate.
b. airway patency.
A nurse is preparing to perform endotracheal tube care and plans to use tape to secure the tube. Which of the following is an appropriate preparatory action for this procedure? a. cut a piece of tape that reaches posterioly from naris to naris b. have a tincture of benzoin ready to apply to the patient's face c. prepare an astringent solution for cleaning the patient's face d. open a package of sterile gloves so they are ready to use
b. have a tincture of benzoin ready to apply to the patient's face Tincture of benzoin or a liquid adhesive not only protects the pt's skin, but it also prepares the skin around the nose or mouth and on the face for better adherence of the tape.
A Yankauer (tonsil tip) suction catheter is used for what?
it helps clear secretions from the mouth. Patients who require this type of suctioning can cough effectively but cannot swallow or expectorate secretions. Wear clean gloves when using a Yankauer suction catheter and use it multiple times for the same patient before discarding the device.
During trach care, which of the following should the nurse place underneath the flanges of the outer cannula? a) commercially prepared transparent dressing b) cotton filled gauze squares c) commercially prepared fenestrated dressing d) twill tape
c) commercially prepared fenestrated dressing A commercially prepared tracheostomy dressing is made of material that does not unravel and has a fenestration (slit) designed to fit around the tracheostomy tube under the flanges.
a nurse is caring for a pt who has a tracheostomy tube with an inner cannula in place. wotf supplies should the nurse use to dry the inner canula of the pt's tracheostomy tube after cleaning it? a-paper towels b-cotton-tipped applicators c-folded pipe cleaners d-facial tissue
c- folded pipe cleaners Pipe cleaners remain intact w/o leaving any particulate matter the pt could aspirate.
When suctioning secretions that are collecting in an endotracheal tube, the nurse does not apply suction for more than how many seconds? a. 5 seconds b. 10 seconds c. 15 seconds d. 20 seconds
c. 15 seconds
You are a new grad assigned to the care of a patient with a newly inserted tracheostomy. The trach tube is a #6 cuffed Shiley. Which pressure should the cuff pressure be maintained at? a. 50-75 mm Hg b. 5-10 mm Hg c. 15-25 mm Hg d. 35-50 mm Hg
c. 15-25 mm Hg
Which of the following patients does NOT have an indication for tracheostomy? a. A stroke patient with a decreased of consciousness after several days b. A patient with pneumonia who has excessive retained secretions c. A post-op hernia repair patient who is expected to be on a ventilator for 5 days d. A patient who has a foreign body lodged in the upper airway
c. A post-op hernia repair patient who is expected to be on a ventilator for 5 days
Which response would the nurse report immediately if it occurred in association with nasotracheal suctioning? a. Patient complains of discomfort during the procedure b. Patient has a severe bout of nonproductive coughing and complains of sore throat c. After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88% d. Patient's pulse rate increases by 10 beats/min
c. After oxygen delivery device has been reapplied on completion of the procedure, patient's pulse oximetry reading falls to 88% This decline in peripheral blood oxygen saturation must be reported. It represents a decline in the patient's condition following a procedure that should have improved his or her SpO2 reading.
How should the patient use a voice prosthesis? a. Place a vibrating device in the mouth b. Place a speaking valve over the stoma c. Block the stoma entrance with a finger d. Swallow air using Valsalva's manoeuvre
c. Block the stoma entrance with a finger
While suctioning the nasotracheal airway, the nurse notes that a patient's pulse rate has fallen from 102 beats/min to 80 beats/min. What is the best course of action? a. Encourage the patient to take several deep breaths. b. Interrupt suction to the catheter for at least 10 seconds. c. Discontinue suctioning by removing the suction catheter. d. Assess the patient's pulse oximetry reading to see if oxygenation is adequate.
c. Discontinue suctioning by removing the suction catheter. A drop in pulse of 20 beats/min or more necessitates discontinuation of suctioning and removal of the catheter.
The nurse is caring for a patient with a chest tube in the right thorax. On first assessment, the nurse notes bubbling in the water-seal chamber. This patient is scheduled to undergo a chest x-ray examination, and the transporters have arrived to take him by wheelchair to the radiology department. The nurse considers whether the chest tube should be clamped during the trip to the radiology department. Which correct decision does the nurse make? a. Clamp the chest tube, but vent the system to air. b. Clamp the chest tube, and disconnect it from the wall suction. c. Do not clamp the chest tube, and disconnect it from the wall suction. d. Do not clamp the chest tube and connect it to temporary intermittent suction.
c. Do not clamp the chest tube, and disconnect it from the wall suction. A bubbling chest tube (in the water-seal portion) should never be clamped because it provides the only exit for air accumulating in the pleural space. If the tube is clamped, tension pneumothorax could occur, which could be fatal.
Which of the following may be a cause for tracheostomy tube dislodgement? a. Erosion or rupture of blood vessels surrounding the stoma b. Dried or excessive secretions surrounding the stoma c. Excessive manipulation or suctioning d. Narrowing of tracheal lumen owing to scarring caused by tracheal irritation
c. Excessive manipulation or suctioning
Which action may be delegated to nursing assistive personnel (NAP) regarding the care of a patient with a tracheostomy? a. Performing tracheostomy care for a patient whose tracheostomy was placed 1 week ago b. Removing the outer cannula and placing the obturator c. Holding the tracheostomy tube while the nurse changes the neck ties d. Monitoring oxygen saturation levels and placing oxygen if needed
c. Holding the tracheostomy tube while the nurse changes the neck ties
Which of the following is NOT an appropriate action when a tracheostomy tube is blocked? a. Remove inner cannula b. Call a code blue c. Insert plug and encourage coughing d. Attempt to suction
c. Insert plug and encourage coughing
Which of the following may be a cause for tracheal stenosis to occur in a patient with a tracheostomy? a. Surgical intervention b. Erosion or rupture of blood vessel c. Narrowing of tracheal lumen owing to scarring caused by tracheal irritation d. Tracheal wall necrosis leading to fistula formation
c. Narrowing of tracheal lumen owing to scarring caused by tracheal irritation
The function of the emergency tracheostomy equipment bag is to: a. Provide equipment for weaning procedures b. Provide equipment for ventilation c. Provide equipment for changing or reinserting a tracheostomy tube in an emergency d. Provide equipment for dilating the stoma when patient is having trouble coughing
c. Provide equipment for changing or reinserting a tracheostomy tube in an emergency
suction
negative force used to withdraw air, fluid, or secretions out of a body cavity or part
Which of the following is the priority nursing assessment in the care of a patient who has a tracheostomy? a. Electrolyte levels and daily weights b. Assessment of speech and swallowing c. Respiratory rate and oxygen saturation d. Pain assessment and assessment of mobility
c. Respiratory rate and oxygen saturation The priority assessment in the care of a patient with a tracheostomy focuses on airway and breathing. These assessments supersede the nurse's assessments that may also be necessary, such as nutritional status, speech, pain, and swallowing ability.
Which of the following is NOT considered a sign of stomal infection? a. Redness around the area b. Thick mucosal discharge c. Subcutaneous emphysema d. Crusting around the stoma
c. Subcutaneous emphysema
What is the purpose of splinting the abdomen with a small pillow during controlled coughing? a. To minimize chest discomfort caused by the coughing b. To expand lung capacity during the inspiratory phase of the cough c. To maximize transdiaphragmatic pressure during the expiratory phase of the cough d. To focus the patient's attention on the abdominal muscles used during the cough
c. To maximize transdiaphragmatic pressure during the expiratory phase of the cough Splinting the abdomen will increase transdiaphragmatic pressure.
Bradycardia or hypotension may result from suctioning due to: a. Patient agitation b. Hypoxemia c. Vagal nerve stimulation d. Hyperoxygenation
c. Vagal nerve stimulation
You are a new nurse assigned to the care of a patient with a newly inserted tracheostomy. You know that checking proper placement of the trach is an essential part of your assessment. How often should you be checking the trach placement? a. Q1H - Q2H b. Q8H - Q12H c. Once a shift d. Q2H - Q4H
d) Q2H - Q4H
Which of the following may be a cause for subcutaneous emphysema in a patient with a tracheostomy? a. Dried or excessive secretions b. Tracheal wall necrosis leading to fistula formation c. Erosion or rupture of blood vessel, or both d. Air escapes from the incision to the subcutaneous tissue
d. Air escapes from the incision to the subcutaneous tissue
Tracheostomy tubes are preferred over Endotracheal tubes for long-term ventilation. Which of the following describes why? a. Endotracheal tubes impede oral hygiene. b. Endotracheal tubes are not well tolerated by an awake patient. c. Endotracheal tubes can cause pressure sores and mucosal damage to the lips and mouth. d. All of the above.
d. All of the above
Why should the cuff inflation pressure of a tracheostomy tube not exceed 20 mm Hg? a. Compresses tracheal capillaries b. Limits blood flow c. Predisposes to tracheal necrosis d. All of the above
d. All of the above
Which of the following statements best describes the correct method for artificial airway suctioning? a. Use clean gloves to complete the procedure. b. Insert the catheter 1-2 cm during expiration c. Lightly coat 2-3 cm of catheter with water soluble lubricant d. Apply intermittent suction while withdrawing the catheter
d. Apply intermittent suction while withdrawing the catheter
While in the recovery room, a patient with a total laryngectomy is suctioned and has bloody mucus with some clots. Which of the following nursing interventions would apply? a. Notify the physician immediately b. Place the patient in the prone position to facilitate drainage c. Instill 3 mL of normal saline into the tracheostomy tube to loosen secretions d. Continue the assessment of the patient, including oxygen saturation, respiratory rate, and breath sounds
d. Continue the assessment of the patient, including oxygen saturation, respiratory rate, and breath sounds
During an admission interview, a patient who is required to stay in the supine position reports, "I can't breathe well while I'm lying down." What would the nurse do first to help this patient? a. Notify the health care provider of the patient's complaint. b. Request that the health care provider prescribe oxygen therapy. c. Interview the patient concerning the onset of this problem. d. Instruct the patient to use two bed pillows when lying supine.
d. Instruct the patient to use two bed pillows when lying supine. Instructing the patient to use two bed pillows when lying supine is an appropriate intervention at this time.
Which action is part of the preparation for nasotracheal suctioning? a. Place the patient in a supine position. b. Preoxygenate the patient with 100% oxygen. c. Suction 100 mL of warm tap water to flush the suction catheter. d. Place water-soluble lubricant onto the open sterile catheter package.
d. Place water-soluble lubricant onto the open sterile catheter package.
hyperventilation
excessively rapid or deep breathing
Nasopharyngeal and nasotracheal suctioning
help remove secretions from the lower airway of patients who cannot cough and do not have an artificial airway in place. To perform either type of suctioning, insert a small, sterile, flexible catheter into the nares until the tip reaches the pharynx or the trachea. Wear sterile gloves and use the catheter only once.
