A nurse is preparing to perform tracheostomy care for a patient. What is the recommended interval for performing tracheostomy care?

Every 2 to 4 hours.

Every 4 to 6 hours.

Every 6 to 8 hours.

Every 8 to 12 hours.

Every 12 to 24 hours.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Performing tracheostomy care every 2 to 4 hours would be too frequent for most patients and may cause unnecessary disruption and discomfort. This interval is not the recommended standard of care.

Choice B rationale:

Tracheostomy care every 4 to 6 hours strikes a balance between maintaining airway hygiene and minimizing excessive handling of the tracheostomy site, reducing the risk of complications such as infection or irritation.

Choice C rationale:

Waiting to perform tracheostomy care every 6 to 8 hours may increase the risk of mucus buildup and potential complications, especially in patients with high secretions or respiratory issues.

Choice D rationale:

Extending the interval to every 8 to 12 hours may lead to inadequate airway clearance and increased risk of complications in patients who require more frequent care.

Choice E rationale:

Waiting to perform tracheostomy care every 12 to 24 hours is too infrequent for most patients and may not be sufficient to maintain a patent airway and prevent complications.

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Correct Answer is A

Explanation

Choice A rationale:

This response acknowledges the patient's concern and provides a realistic expectation of potential discomfort during the procedure. It offers reassurance that any pain experienced will be brief.

Choice B rationale:

This response is not entirely accurate. While the procedure itself may not cause pain, some patients may experience discomfort during tracheostomy suctioning due to the sensation of suction in the airway.

Choice C rationale:

This response is not appropriate as it exaggerates the potential pain, causing unnecessary distress to the patient.

Choice D rationale:

Administering pain medication solely for the discomfort associated with tracheostomy suctioning is not standard practice. Pain medication should only be given for clinically significant pain or as part of a larger pain management plan.

A. "I will monitor the cuff pressure to keep it between 20 to 25 cm H2O.". B. "The fenestration should remain open at all times.". C. "The inner cannula is only used when the patient requires mechanical ventilation.". D. "A fenestrated tube is used for patients with a low risk of aspiration.". E. "Metal tracheostomy tubes are commonly used for long-term ventilation.".

Correct Answer is D

Explanation

Choice D rationale:

This statement is correct. A fenestrated tracheostomy tube is designed for patients with a low risk of aspiration and are weaning from mechanical ventilation. The fenestration allows the patient to breathe through the upper airway, promoting speech and facilitating the weaning process. The fenestration can be temporarily occluded to assess the patient's readiness for decannulation.

Choice A rationale:

Monitoring cuff pressure is essential, but the suggested range of 20 to 25 cm H2O is not universally applicable. The appropriate cuff pressure range may vary depending on the patient's condition, and it should be individualized based on the patient's needs.

Choice B rationale:

Keeping the fenestration open at all times is not accurate. The fenestration can be open to allow airflow during weaning and speech therapy, but it can be temporarily occluded when assessing the patient's ability to breathe without the tube.

Choice C rationale:

The inner cannula is not solely used during mechanical ventilation. It is also used for routine cleaning and maintenance of the tracheostomy tube, regardless of the patient's ventilation status.

Choice E rationale:

Metal tracheostomy tubes are not commonly used for long-term ventilation. They are mostly used in specific situations where a plastic tube may not be suitable, such as when there is a risk of tube distortion or damage. Plastic tubes are more commonly used for long-term ventilation due to their availability, flexibility, and ease of use.

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A nurse is preparing to perform tracheostomy care for a patient. What is the recommended interval for performing tracheostomy care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a tracheostomy tube expresses concern about the procedure and asks, "Is this going to hurt?”. Which response by the nurse is most appropriate?

Correct Answer is A

Explanation

Which statement by the nurse regarding tracheostomy care is correct?

Correct Answer is D

Explanation

A nurse is suctioning a tracheostomy tube and wants to ensure proper oxygenation between attempts. How long should the nurse wait between each suctioning attempt?

A nurse is educating a patient with a tracheostomy on communication methods. Which information should the nurse include?

A client with a tracheostomy tube is experiencing dry and crusted secretions. What intervention would the nurse provide to address this issue?

A client has a tracheostomy and is at risk of tracheoesophageal fistula (TEF). Which of the following interventions should the nurse implement to prevent TEF? Select all that apply:

A nurse is providing care for a patient with a tracheostomy who complains of increased coughing, difficulty breathing, and stridor. The nurse assesses that the tracheal lumen has narrowed due to scar formation. Which statement by the nurse is appropriate?

A client with a tracheostomy tube is ready to wean from mechanical ventilation and also requires speech therapy. What type of tracheostomy tube would be the most appropriate choice for this client?

(Select all that apply). A nurse is suctioning a tracheostomy tube for a patient. Which of the following actions are correct during the suctioning process?

A nurse is preparing to suction a client's tracheostomy tube. Which step should the nurse perform first during the suctioning procedure?