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:

This choice is not the most relevant information for the patient with a tracheostomy regarding communication methods. Effective oral communication with the tube in place may be challenging, and other options should be explored.

Choice B rationale:

While electronic devices can be helpful for communication, they may not be the most practical option for a patient with a tracheostomy, especially during emergencies when devices may not be readily available.

Choice C rationale:

This choice is somewhat relevant but not the most appropriate. While written communication is an option, it may not be the primary method used with a tracheostomy.

Choice D rationale:

This is the correct choice. Teaching the patient how to use speaking valves to facilitate speech with the tracheostomy tube in place can significantly improve communication. Speaking valves allow airflow during inhalation and redirect exhaled air through the vocal cords, enabling speech while maintaining a closed respiratory system during exhalation. This is a valuable communication method for patients with tracheostomies.

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 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 educating a patient with a tracheostomy on communication methods. Which information should the nurse include?

Correct Answer is D

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

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

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?

Which statement by the nurse regarding tracheostomy care is correct?

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?

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

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:

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?