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?

"This might be due to an infection. Let's monitor for any fever or increased secretions.".

"You should try to expectorate secretions frequently to help improve your breathing.".

"Let's ensure the tracheostomy tube is securely positioned in the midline to prevent further narrowing.".

"We might need to use a larger tracheostomy tube to maintain an air seal at the stoma.".

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is D

Explanation

Choice A rationale:

Positioning the patient in semi-Fowler's position (Choice A) is an important step in tracheostomy care, but it is not the first step during the suctioning procedure. Semi-Fowler's position helps promote lung expansion and allows for better visualization during the procedure.

Choice B rationale:

Applying a new dressing around the stoma (Choice B) is essential after suctioning to maintain cleanliness and prevent infection. However, it is not the first step in the suctioning procedure. The nurse should first gather the necessary equipment.

Choice C rationale:

Cleaning the inner cannula with hydrogen peroxide (Choice C) is not the first step during suctioning. The nurse should gather equipment and supplies first before performing any cleaning or other procedures.

Choice E rationale:

Removing the old dressing and discarding it in a moisture-resistant bag (Choice E) is an important step, but it should come after the nurse gathers the necessary equipment for the suctioning procedure.

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 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

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

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

Explanation

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 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 patient with a tracheostomy tube is speaking with a low risk of aspiration. What type of tracheostomy tube would be most suitable for this patient?

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

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

A nurse is preparing to suction a tracheostomy tube for a patient. What position should the nurse place the patient in?

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?