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 B
Explanation
Choice A rationale:
While notifying the healthcare provider is essential, the priority action in this situation is to stop the bleeding to prevent further complications.
Choice B rationale:
Applying direct pressure to the tracheostomy stoma is the first action the nurse should take to control the bleeding and stabilize the patient.
Choice C rationale:
Administering fluids and blood products may be necessary later, but it is not the first action to take when dealing with active bleeding.
Choice D rationale:
Ensuring proper positioning and alignment of the tracheostomy tube is important, but it is not the priority in this critical situation.
Correct Answer is C
Explanation
Choice A rationale:
Placing the patient in a prone position (Choice A) would not be suitable for suctioning a tracheostomy tube as it may impede breathing and proper access to the tracheostomy site.
Choice B rationale:
Placing the patient in a supine position (Choice B) is not the optimal position for tracheostomy suctioning. Semi-Fowler's position is preferred as it allows better lung expansion and facilitates the suctioning procedure.
Choice D rationale:
Placing the patient in Trendelenburg position (Choice D) is not appropriate for tracheostomy suctioning. Trendelenburg position is typically used for certain cardiovascular conditions and not for tracheostomy care.
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