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 B

Explanation

Choice A rationale:

This response is dismissive of the patient's feelings and may increase their anxiety. It does not address the patient's concern appropriately.

Choice B rationale:

This response acknowledges the patient's anxiety and provides a clear explanation for the necessity of the procedure. It is empathetic and supportive while also emphasizing the importance of the intervention.

Choice C rationale:

This response is not entirely reassuring and may not be accurate. Simply asking the patient to trust the nurse without explaining the procedure further may not alleviate the patient's anxiety.

Choice D rationale:

Skipping the procedure without a valid reason may compromise the patient's airway and respiratory function. Postponing essential procedures is not appropriate unless there are specific clinical reasons for doing so.

A. Clean the stoma with hydrogen peroxide. B. Change the ties or straps every 4 hours. C. Inspect the stoma for signs of infection. D. Reinsert the inner cannula and lock it in place. E. Apply a new dressing around the stoma and secure it with tape.

Correct Answer is ["C","D","E"]

Explanation

Choice A rationale:

Cleaning the stoma with hydrogen peroxide (Choice A) is not recommended for tracheostomy care. Hydrogen peroxide can be irritating and damaging to the tissues. Normal saline solution should be used to clean the stoma.

Choice B rationale:

Changing the ties or straps every 4 hours (Choice B) is not necessary unless they are soiled or loose. Frequent changes may irritate the skin and increase the risk of infection. Straps should be changed only when needed.

Choice C rationale:

Inspecting the stoma for signs of infection (Choice C) is a crucial step in tracheostomy care. Signs of infection may include redness, swelling, discharge, or foul odor. Prompt identification and treatment of infection are essential to prevent complications.

Choice E rationale:

Applying a new dressing around the stoma and securing it with tape (Choice E) is essential after tracheostomy care to maintain cleanliness and protect the stoma. Proper dressing helps prevent infection and skin breakdown.

Suctioning a tracheostomy tube is a sterile, invasive technique that requires a nurse or a respiratory therapist. It is done to remove secretions from the tube and prevent obstruction, infection, or hypoxia. The steps of suctioning a tracheostomy tube are:

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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 nurse is about to insert the suction catheter into the patient's tracheostomy tube. The patient says, "I'm feeling anxious about this.”What would be the nurse's appropriate response?

Correct Answer is B

Explanation

Select all the appropriate steps a nurse should take during tracheostomy care.

Correct Answer is ["C","D","E"]

Explanation

A client with a tracheostomy is at risk of developing tracheomalacia. Which statement by the client indicates a need for further education?

A nurse is preparing to suction a patient's tracheostomy tube and observes signs of infection around the stoma. What action should the nurse take?

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

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

A nurse is providing care for a patient with a tracheostomy tube. What type of tracheostomy tube would be most suitable for a patient who requires mechanical ventilation or has a high risk of aspiration?

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?

(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?