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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

The most crucial measure to prevent cross-contamination during sterile suctioning is the use of personal protective equipment (PPE). PPE, including gloves, gown, mask, and eye protection, creates a barrier between the healthcare provider and the patient's respiratory secretions, reducing the risk of infection transmission.

Choice B rationale:

Proper disposal of waste materials is important for infection control, but it is not the most critical measure to prevent cross-contamination during sterile suctioning. While proper waste disposal is necessary to reduce the spread of infections, using PPE is more directly related to preventing cross-contamination during the procedure.

Choice C rationale:

Environmental cleaning of the suction device is essential for infection control, but it is not the most important measure to prevent cross-contamination during sterile suctioning. The immediate and direct protection provided by PPE is more effective in reducing the risk of transmission during the procedure.

Choice D rationale:

Performing hand hygiene before and after the procedure is vital for infection control, but it is not the most crucial measure to prevent cross-contamination during sterile suctioning. While hand hygiene is essential for reducing the spread of infections, using PPE provides an additional layer of protection during the procedure.

A. "I have a history of epiglottitis.". B. "I sometimes get laryngeal edema.". C. "I have difficulty clearing my secretions.". D. "I use an artificial airway at night.".

Correct Answer is A

Explanation

Choice A rationale:

Epiglottitis is an inflammation of the epiglottis, which is a crucial structure in protecting the airway during swallowing. Suctioning in patients with a history of epiglottitis can be dangerous because it can cause further irritation and swelling of the epiglottis, potentially leading to airway obstruction and respiratory distress. Therefore, sterile suctioning is contraindicated in patients with a history of epiglottitis.

Choice B rationale:

Laryngeal edema refers to swelling of the larynx, which can also compromise the airway. While it is essential to monitor and manage laryngeal edema carefully, it is not an absolute contraindication for sterile suctioning. In some cases, suctioning may be necessary to maintain a patent airway, but it should be performed with caution and by experienced personnel.

Choice C rationale:

Difficulty clearing secretions is a common indication for sterile suctioning. Patients who have difficulty clearing their secretions may need suctioning to prevent the accumulation of mucus and maintain a clear airway. Therefore, this statement does not indicate a contraindication for the procedure.

Choice D rationale:

Using an artificial airway at night, such as a tracheostomy tube, indicates that the patient may require suctioning to maintain airway patency. While having an artificial airway increases the risk of infection and other complications, it is not a contraindication for sterile suctioning if clinically indicated.

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A nurse is performing tracheostomy care for a patient with a tracheostomy tube (TT). Which action should the nurse include in the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching infection control principles for sterile suctioning. Which measure is the most important to prevent cross-contamination during the procedure?

Correct Answer is A

Explanation

A nurse is educating a group of patients about sterile suctioning. Which patient statement indicates a contraindication for this procedure?

Correct Answer is A

Explanation

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When suctioning a patient with an endotracheal tube (ETT), the nurse should limit the suctioning time to:

A nurse is performing tracheostomy care for a patient with a tracheostomy tube (TT). Which action should the nurse include in the procedure?