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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
Maintaining proper cuff pressure prevents pressure-related injuries and potential tracheoesophageal fistula (TEF) formation.
Choice B rationale:
Progressing to a deflated cuff or cuffless tube reduces the risk of TEF by minimizing pressure on the tracheal tissues.
Choice C rationale:
Tracheal dilation or surgical intervention may be necessary if TEF has already developed but is not a preventive measure.
Choice D rationale:
Using a small soft feeding tube instead of a nasogastric tube for tube feedings reduces the risk of trauma to the tracheal tissues and lowers the risk of TEF formation.
Choice E rationale:
Administering oxygen by mask may be necessary for oxygenation, but it is not specifically related to preventing tracheoesophageal fistula formation.
Correct Answer is D
Explanation
Choice A rationale:
This choice is not the most relevant information for the patient with a tracheostomy regarding communication methods. Effective oral communication with the tube in place may be challenging, and other options should be explored.
Choice B rationale:
While electronic devices can be helpful for communication, they may not be the most practical option for a patient with a tracheostomy, especially during emergencies when devices may not be readily available.
Choice C rationale:
This choice is somewhat relevant but not the most appropriate. While written communication is an option, it may not be the primary method used with a tracheostomy.
Choice D rationale:
This is the correct choice. Teaching the patient how to use speaking valves to facilitate speech with the tracheostomy tube in place can significantly improve communication. Speaking valves allow airflow during inhalation and redirect exhaled air through the vocal cords, enabling speech while maintaining a closed respiratory system during exhalation. This is a valuable communication method for patients with tracheostomies.
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