A nurse is caring for a client who has a tracheostomy.
Which of the following interventions should the nurse implement when performing tracheostomy care?
Encourage the client to take showers.
Apply suction when inserting the catheter.
Clean the inner cannula with soap and water.
Use sterile technique.
The Correct Answer is D
Choice A rationale
Encouraging the client to take showers without specific precautions is dangerous for someone with a tracheostomy. Water can easily enter the stoma and be aspirated directly into the lungs, leading to drowning or severe aspiration pneumonia. If a client with a tracheostomy showers, they must use a specialized shield or cover to prevent water entry. This intervention is not a standard part of tracheostomy care and requires significant safety education to prevent life-threatening respiratory complications.
Choice B rationale
Suction should never be applied while inserting the catheter into the tracheostomy tube. Applying suction during insertion increases the risk of mucosal trauma and depletes the client's oxygen levels by removing air from the lungs before the procedure even begins. Suctioning should only be performed intermittently while withdrawing the catheter using a rotating motion. This technique minimizes damage to the tracheal wall and reduces the incidence of hypoxia, which can cause cardiac arrhythmias or distress.
Choice C rationale
Cleaning the inner cannula with soap and water is inappropriate for tracheostomy care. Standard protocol requires using sterile saline or a mixture of sterile saline and hydrogen peroxide, depending on the facility policy and the amount of crusting. Soap can leave residues that irritate the respiratory mucosa or cause chemical pneumonitis if inhaled. Using sterile solutions ensures that the airway remains free from pathogens and irritants, maintaining the integrity of the respiratory tract and the stoma site.
Choice D rationale
Using sterile technique is mandatory for tracheostomy care in the hospital setting to prevent healthcare-associated infections like tracheobronchitis or pneumonia. The tracheostomy bypasses the upper airway's natural filtering and humidification systems, leaving the lower respiratory tract vulnerable to environmental pathogens. Sterile gloves and equipment must be used when handling the inner cannula and performing suctioning to maintain a sterile field. This practice is vital for protecting the client's compromised airway from colonization by pathogenic bacteria.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Positioning a patient flat on their back, or supine, is contraindicated for individuals with chronic obstructive pulmonary disease who are practicing breathing techniques. This position causes the abdominal organs to push upward against the diaphragm, restricting its downward movement and increasing the work of breathing. Patients should ideally be in an upright or semi-Fowler position to allow for maximal diaphragmatic excursion and better lung expansion. Normal diaphragmatic movement is essential for reducing the respiratory rate and improving ventilation efficiency in diseased lungs.
Choice B rationale
Forceful coughing during the exhalation phase of pursed-lipped breathing is counterproductive and physiologically damaging for patients with chronic obstructive pulmonary disease. These patients often have weakened alveolar walls and narrowed airways. Forceful coughing increases intra-thoracic pressure, which can cause the small, floppy airways to collapse prematurely, trapping more air in the distal lungs. The goal of this breathing technique is to maintain a steady, controlled outward flow of air to keep the airways open, rather than creating turbulent or obstructive pressure.
Choice C rationale
Inhaling through the nose and exhaling through the mouth is the core physiological mechanism of pursed-lipped breathing. Inhaling through the nasal passages allows the air to be filtered, warmed, and humidified. Exhaling through pursed lips creates a small amount of positive end-expiratory pressure within the airways. This back-pressure keeps the bronchioles open longer during the expiratory phase, which facilitates the removal of trapped carbon dioxide and allows for more effective oxygen exchange in the alveoli, ultimately reducing the patient's shortness of breath.
Choice D rationale
In pursed-lipped breathing, the physiological goal is to ensure that the expiratory phase is significantly longer than the inspiratory phase. Typically, the nurse instructs the patient to exhale for at least twice as long as they inhale. Prolonging expiration helps to empty the lungs of stale, carbon-dioxide-rich air that is often trapped in the hyperinflated lungs of those with chronic obstructive pulmonary disease. If inspiration is longer than expiration, the patient will continue to experience air trapping, which increases the residual volume and worsens dyspnea.
Correct Answer is A,B,C,D,E
Explanation
38 The correct sequence is Choice A, Choice B, Choice C, Choice D, Choice E, Choice F.
Step 1: The correct order begins with Choice A, where the patient must inhale and exhale completely to clear the lungs and create space for the medication.
Step 2 is Choice B, placing the lips firmly around the mouthpiece to create a seal.
Step 3 is Choice C, inhaling slowly while activating the canister.
Step 4 is Choice D, holding the breath for 10 seconds to allow the medication to settle in the bronchioles.
Step 5 is Choice E, exhaling through pursed lips.
Step 6 is Choice F, waiting 60 seconds.
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