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 D
Explanation
Choice D rationale:
When suctioning patients with an artificial airway, using disposable plastic catheters is preferred to reduce the risk of infection. Disposable catheters are single-use and discarded after each procedure, minimizing the potential for contamination and cross-infection between patients.
Choice A rationale:
Glass suctioning catheters are not preferred because they cannot be effectively sterilized for reuse. Reusable materials carry a higher risk of infection transmission and should be avoided when possible.
Choice B rationale:
Metal suctioning catheters are also not the preferred choice for reducing the risk of infection. Like glass catheters, they can be difficult to clean and sterilize adequately for safe reuse. Using disposable materials, like plastic catheters, is a safer option.
Choice C rationale:
While reusable silicone catheters may be more flexible and gentler on the airway, they are not the preferred choice for infection control. Like other reusable materials, they carry a higher risk of contamination and are not as easily disposed of as disposable plastic catheters.
Correct Answer is C
Explanation
Choice A rationale:
Continuing suctioning when the patient is experiencing bronchospasm and increased intracranial pressure can worsen their condition and potentially lead to further complications. It is not appropriate to continue suctioning in this situation.
Choice B rationale:
Adjusting the pressure on the suction device may not be sufficient to address the patient's current condition. Stopping suctioning and providing appropriate interventions are more crucial in this situation.
Choice C rationale:
Stopping suctioning immediately is the most appropriate action when the patient experiences bronchospasm and increased intracranial pressure. The nurse should assess the patient's airway, administer bronchodilators or other prescribed treatments as needed, and seek medical assistance if necessary.
Choice D rationale:
Increasing the suction pass time is not recommended as it can exacerbate the patient's condition and lead to complications. The focus should be on stopping suctioning and providing appropriate interventions.
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