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","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.

A. Cuffed. B. Uncuffed. C. Fenestrated. D. Double-lumen. E. Metal.

Correct Answer is A

Explanation

Choice A rationale:

A cuffed tracheostomy tube is most suitable for a patient who requires mechanical ventilation or has a high risk of aspiration. The cuff is inflated to create a seal between the trachea and the tube, preventing aspiration of oral secretions or gastric contents into the airway. This is crucial for patients on mechanical ventilation to ensure effective ventilation and prevent complications like ventilator-associated pneumonia.

Choice B rationale:

Uncuffed tracheostomy tubes do not have an inflatable cuff, making them unsuitable for patients who require mechanical ventilation or have a high risk of aspiration. They are more appropriate for patients who can protect their own airway and have minimal risk of aspiration.

Choice C rationale:

Fenestrated tracheostomy tubes have an opening or fenestration on the tube that allows airflow through the upper airway, bypassing the tracheostomy tube. These tubes are used for patients who are weaning off mechanical ventilation and require speech therapy. They are not the most suitable choice for patients who need mechanical ventilation or have a high aspiration risk.

Choice D rationale:

Double-lumen tracheostomy tubes have two separate tubes, which can be used for independent lung ventilation in certain situations. They are not specifically designed for patients requiring mechanical ventilation or with a high risk of aspiration.

Choice E rationale:

Metal tracheostomy tubes are not commonly used for patients requiring mechanical ventilation or with a high risk of aspiration. Metal tubes may be used in certain cases, but they are not the most suitable choice for this patient population.

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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 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:

Correct Answer is ["A","B","D"]

Explanation

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?

Correct Answer is A

Explanation

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

(Select all that apply). A nurse is gathering equipment for suctioning a tracheostomy tube. Which of the following items should the nurse include in the setup?

A nurse is caring for a patient with a tracheostomy. The patient suddenly develops bright red bleeding from the tracheostomy stoma, pulsation of the tracheostomy tube in synchrony with the heartbeat, hypotension, and tachycardia. What should the nurse do first?

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?

Which of the following patients would require a higher suction pressure during tracheostomy tube suctioning?

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 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?