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 A
Explanation
Choice A rationale:
(Correct) After sterile suctioning, it is essential to reposition the patient to a comfortable and safe position, ensuring proper alignment and support to prevent complications.
Choice B rationale:
(Incorrect) While documentation is crucial, ensuring the patient's safety and comfort should be the immediate priority after the procedure.
Choice C rationale:
(Incorrect) The nurse should not remove the catheter and tubing from the artificial airway immediately after suctioning, as it may still be needed for subsequent interventions.
Choice D rationale:
(Incorrect) Assessing the patient's response to suctioning is essential, but ensuring safety and repositioning take precedence immediately after the procedure.
Correct Answer is B
Explanation
Choice A rationale:
The nurse should indeed provide reassurance and answer any questions before performing any procedure, as this helps to alleviate the patient's anxiety and ensure they are well-informed about the procedure.
Choice B rationale:
Gathering the necessary equipment and supplies is essential before starting sterile suctioning. This ensures that the nurse has everything needed for the procedure, promoting efficiency and safety.
Choice C rationale:
Connecting the suction tubing to the suction device is an important step in the suctioning process, but it should be done after gathering all the necessary equipment and supplies.
Choice D rationale:
Preoxygenating the patient with 100% oxygen is not a step required before suctioning. Preoxygenation may be necessary before some procedures, but it is not specifically indicated for sterile suctioning.
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