A client with a tracheostomy is at risk of developing tracheomalacia. Which statement by the client indicates a need for further education?

"I should inform the nurse if I notice any food particles in my tracheal secretions.".

"I may need a larger tracheostomy tube to prevent an air leak at the stoma.".

"I should try to minimize the time the cuff is inflated to prevent tracheal dilation.".

"I will monitor the cuff pressure and air volumes closely for any changes.".

Answer and Explanation

Correct Answer : B,C

Choice A rationale:

This statement is correct. The client should inform the nurse if they notice any food particles in their tracheal secretions as it could indicate aspiration and require immediate attention.

Choice B rationale:

This statement indicates a need for further education. A larger tracheostomy tube to prevent an air leak at the stoma is not an appropriate intervention for tracheomalacia. Tracheomalacia is the weakening of the tracheal cartilage, and a larger tube would not address this underlying issue.

Choice C rationale:

This statement is also incorrect. Minimizing the time the cuff is inflated may be beneficial to prevent tracheal stenosis but would not prevent tracheomalacia, which is a different condition altogether.

Choice D rationale:

This statement is correct. Monitoring cuff pressure and air volumes closely is essential to prevent complications and ensure appropriate cuff inflation.

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Correct Answer is ["A","B","D"]

Explanation

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.

A. Sterile gloves. B. Sterile water or saline. C. Pulse oximeter. D. Sphygmomanometer.

Correct Answer is ["B","E"]

Explanation

Choice A rationale:

Sterile gloves are essential for aseptic technique during tracheostomy suctioning to prevent the introduction of infection. However, they are not included in the setup, as they are worn by the nurse performing the procedure.

Choice B rationale:

Sterile water or saline is necessary for suctioning to moisten the suction catheter and facilitate the removal of secretions without causing trauma to the airway. Therefore, it should be included in the setup.

Choice C rationale:

A pulse oximeter is used to monitor the patient's oxygen saturation and is not directly related to tracheostomy suctioning. While continuous monitoring of oxygen saturation is essential during and after the procedure, it is not a part of the setup.

Choice D rationale:

A sphygmomanometer is used to measure blood pressure and is unrelated to tracheostomy suctioning. It is not required for this procedure.

Choice E rationale:

A non-sterile towel is used to protect the patient's clothing and bed linens from any secretions or spills during the suctioning procedure. It should be included in the setup to maintain cleanliness and prevent contamination.

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A client with a tracheostomy is at risk of developing tracheomalacia. Which statement by the client indicates a need for further education?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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:

Correct Answer is ["A","B","D"]

Explanation

(Select all that apply). A nurse is gathering equipment for suctioning a tracheostomy tube. Which of the following items should the nurse include in the setup?

Correct Answer is ["B","E"]

Explanation

A nurse is about to insert the suction catheter into the patient's tracheostomy tube. The patient says, "I'm feeling anxious about this.”What would be the nurse's appropriate response?

A nurse is preparing to suction a tracheostomy tube for a patient. What position should the nurse place the patient in?

A nurse is suctioning a tracheostomy tube and wants to ensure proper oxygenation between attempts. How long should the nurse wait between each suctioning attempt?

(Select all that apply). A nurse is suctioning a tracheostomy tube for a patient. Which of the following actions are correct during the suctioning process?

A nurse is providing care for a patient with a tracheostomy who complains of increased coughing, difficulty breathing, and stridor. The nurse assesses that the tracheal lumen has narrowed due to scar formation. Which statement by the nurse is appropriate?

Which of the following patients would require a higher suction pressure during tracheostomy tube suctioning?

A nurse is providing care for a patient with a tracheostomy tube. What type of tracheostomy tube would be most suitable for a patient who requires mechanical ventilation or has a high risk of aspiration?

Select all the appropriate steps a nurse should take during tracheostomy care.