A nurse is performing tracheostomy care for a patient with a tracheostomy tube (TT). Which action should the nurse include in the procedure?
Clean the inner cannula once a week.
Deflate the cuff before cleaning the tube.
Use cotton-tipped applicators to clean the stoma.
Change the tracheostomy ties every 24 hours.
The Correct Answer is D
Choice A rationale:
Cleaning the inner cannula once a week is insufficient to maintain proper hygiene for a patient with a tracheostomy tube. The inner cannula should be cleaned more frequently, as directed by the healthcare provider, to prevent the accumulation of secretions and potential respiratory complications.
Choice B rationale:
Deflating the cuff before cleaning the tracheostomy tube is not recommended because it may lead to aspiration of secretions or loss of the airway seal. The cuff should only be deflated when it is necessary to remove or change the tracheostomy tube.
Choice C rationale:
Using cotton-tipped applicators to clean the stoma is not the recommended method for tracheostomy care. Sterile tracheostomy care kits usually include specialized brushes or swabs designed for this purpose, ensuring effective and safe cleaning of the stoma without the risk of shedding fibers or causing injury.
Choice D rationale:
Changing the tracheostomy ties every 24 hours is the appropriate action. Regular changing of the ties helps prevent complications such as skin breakdown, ensures a secure fit of the tracheostomy tube, and reduces the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
To assess lung sounds.
Choice A rationale:
Sterile suctioning is not performed to administer medications. Its primary purpose is to remove secretions and maintain a patent airway.
Choice B rationale:
Sterile suctioning is not done solely for promoting comfort. Its main goal is to clear the airway and prevent respiratory complications.
Choice C rationale:
The purpose of sterile suctioning is to assess lung sounds by removing excess secretions and mucus that may obstruct the airway. This helps in evaluating the patient's respiratory status and identifying any abnormal lung sounds.
Choice D rationale:
Sterile suctioning is not performed to monitor vital signs. Although vital signs may be monitored during the procedure, it is not the primary purpose of suctioning.
Correct Answer is A
Explanation
Choice A rationale:
A closed catheter is the most appropriate choice for suctioning a patient with thick secretions. Closed catheters have a two-way valve that allows for continuous suction while minimizing the risk of introducing air into the patient's airway. This design prevents the loss of oxygen and maintains a closed system, reducing the risk of complications such as hypoxia and infection.
Choice B rationale:
Metal catheters are not suitable for suctioning thick secretions. They can be rigid and may cause trauma to the airway, leading to bleeding and discomfort for the patient.
Choice C rationale:
Large French scale catheters are not specifically designed for thick secretions and may not effectively aspirate them. These catheters are typically used for drainage of body cavities or larger organs.
Choice D rationale:
A catheter with a single opening is not ideal for suctioning thick secretions. It may not provide sufficient suctioning power and could lead to ineffective removal of secretions from the patient's airway.
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