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

Explanation

Choice A rationale:

This choice is not appropriate because increased coughing, difficulty breathing, and stridor suggest a mechanical issue rather than an infection. Monitoring for fever or increased secretions is not addressing the potential cause of the symptoms.

Choice B rationale:

This choice is not appropriate for the presented situation. Expectorating secretions may not directly address the narrowed tracheal lumen due to scar formation, and it is not the primary intervention needed.

Choice C rationale:

This is the correct choice. Ensuring the tracheostomy tube is securely positioned in the midline can help prevent further narrowing of the tracheal lumen. Proper alignment and securing of the tube can optimize airflow and reduce complications related to scar formation.

Choice D rationale:

Using a larger tracheostomy tube may not be the most appropriate action in this situation. Enlarging the tube may not be necessary and could potentially cause other complications. It's better to ensure proper positioning and consider other interventions before resorting to a larger tube.

A. Every 2 to 4 hours. B. Every 4 to 6 hours. C. Every 6 to 8 hours. D. Every 8 to 12 hours. E. Every 12 to 24 hours.

Correct Answer is B

Explanation

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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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

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?

Correct Answer is C

Explanation

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

Correct Answer is B

Explanation

A client with a tracheostomy tube is experiencing dry and crusted secretions. What intervention would the nurse provide to address this issue?

A nurse is suctioning a tracheostomy tube and wants to ensure proper oxygenation between attempts. How long should the nurse wait between each suctioning attempt?

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?

(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?

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

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 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?