A client has a tracheostomy and is at risk of tracheoesophageal fistula (TEF). Which of the following interventions should the nurse implement to prevent TEF? Select all that apply:
Maintain proper cuff pressure.
Progress to a deflated cuff or cuffless tube as soon as possible.
Perform tracheal dilation or surgical intervention if needed.
Use a small soft feeding tube instead of a nasogastric tube for tube feedings.
Administer oxygen by mask to prevent hypoxemia.
Correct Answer : A,B,D
Choice A rationale:
Maintaining proper cuff pressure prevents pressure-related injuries and potential tracheoesophageal fistula (TEF) formation.
Choice B rationale:
Progressing to a deflated cuff or cuffless tube reduces the risk of TEF by minimizing pressure on the tracheal tissues.
Choice C rationale:
Tracheal dilation or surgical intervention may be necessary if TEF has already developed but is not a preventive measure.
Choice D rationale:
Using a small soft feeding tube instead of a nasogastric tube for tube feedings reduces the risk of trauma to the tracheal tissues and lowers the risk of TEF formation.
Choice E rationale:
Administering oxygen by mask may be necessary for oxygenation, but it is not specifically related to preventing tracheoesophageal fistula formation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
Applying continuous suction while inserting the catheter can cause trauma to the tracheal mucosa and increase the risk of bleeding and infection.
Choice B rationale:
Rinsing the catheter with sterile saline between each suctioning attempt helps maintain aseptic technique, preventing the introduction of microorganisms into the airway.
Choice C rationale:
Limiting suctioning attempts to three per session reduces the risk of hypoxia and mucosal damage, ensuring adequate oxygenation and preventing complications.
Choice D rationale:
Withdrawing the catheter gently while applying suction prevents damage to the tracheal walls and minimizes the risk of bleeding.
Choice E rationale:
Hyperoxygenating the patient before and after suctioning helps prevent hypoxemia during the procedure, reducing the risk of complications and ensuring adequate oxygenation.
Correct Answer is B
Explanation
Choice A rationale:
Performing tracheostomy care every 2 to 4 hours would be too frequent for most patients and may cause unnecessary disruption and discomfort. This interval is not the recommended standard of care.
Choice B rationale:
Tracheostomy care every 4 to 6 hours strikes a balance between maintaining airway hygiene and minimizing excessive handling of the tracheostomy site, reducing the risk of complications such as infection or irritation.
Choice C rationale:
Waiting to perform tracheostomy care every 6 to 8 hours may increase the risk of mucus buildup and potential complications, especially in patients with high secretions or respiratory issues.
Choice D rationale:
Extending the interval to every 8 to 12 hours may lead to inadequate airway clearance and increased risk of complications in patients who require more frequent care.
Choice E rationale:
Waiting to perform tracheostomy care every 12 to 24 hours is too infrequent for most patients and may not be sufficient to maintain a patent airway and prevent complications.
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