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?

Proceed with the suctioning as planned.

Report the findings to the healthcare provider.

Clean the area with hydrogen peroxide before suctioning.

Use an antiseptic solution to cleanse the stoma.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Proceeding with the suctioning as planned when signs of infection are present around the tracheostomy stoma can be detrimental to the patient's health. Suctioning in the presence of infection can exacerbate the infection, spread bacteria, and lead to more serious complications.

Choice B rationale:

Reporting the findings of infection to the healthcare provider is the correct action. The healthcare provider needs to assess the infection and determine the appropriate course of action, such as prescribing antibiotics or adjusting the suctioning regimen to prevent further complications.

Choice C rationale:

Cleaning the area with hydrogen peroxide before suctioning is not recommended. Hydrogen peroxide can be harsh on the skin, and using it around the stoma may cause irritation and delay healing. Moreover, cleaning the area without addressing the infection itself does not address the underlying issue.

Choice D rationale:

Using an antiseptic solution to cleanse the stoma is not the appropriate action in the presence of infection. Antiseptic solutions are designed to prevent infections, not treat existing ones. Using an antiseptic could further irritate the area and delay proper treatment for the infection.

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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:

A. "I should inform the nurse if I notice any food particles in my tracheal secretions.". B. "I may need a larger tracheostomy tube to prevent an air leak at the stoma.". C. "I should try to minimize the time the cuff is inflated to prevent tracheal dilation.". D. "I will monitor the cuff pressure and air volumes closely for any changes.".

Correct Answer is ["B","C"]

Explanation

Choice A rationale:

This statement is correct. The client should inform the nurse if they notice any food particles in their tracheal secretions as it could indicate aspiration and require immediate attention.

Choice B rationale:

This statement indicates a need for further education. A larger tracheostomy tube to prevent an air leak at the stoma is not an appropriate intervention for tracheomalacia. Tracheomalacia is the weakening of the tracheal cartilage, and a larger tube would not address this underlying issue.

Choice C rationale:

This statement is also incorrect. Minimizing the time the cuff is inflated may be beneficial to prevent tracheal stenosis but would not prevent tracheomalacia, which is a different condition altogether.

Choice D rationale:

This statement is correct. Monitoring cuff pressure and air volumes closely is essential to prevent complications and ensure appropriate cuff inflation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is ["B","C"]

Explanation

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

Which statement by the nurse regarding tracheostomy care is correct?

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?

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?

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?

(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 perform tracheostomy care for a patient. What is the recommended interval for performing tracheostomy care?

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?