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?

At least 10 seconds.

At least 30 seconds.

At least 1 minute.

At least 3 minutes.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Waiting for at least 10 seconds between each suctioning attempt may not provide sufficient time for the patient's oxygenation to stabilize. This short duration might not allow the patient's oxygen levels to return to an adequate baseline, leading to potential hypoxia during subsequent suctioning attempts.

Choice B rationale:

Waiting for at least 30 seconds between suctioning attempts allows more time for the patient's oxygen levels to recover. This duration strikes a balance between preventing hypoxia and removing secretions effectively. It also helps minimize the risk of complications associated with frequent or rapid suctioning.

Choice C rationale:

Waiting for at least 1 minute between suctioning attempts might be too long, especially if the patient is experiencing respiratory distress or has excessive secretions. Delaying suctioning for this duration could lead to an accumulation of secretions, potentially compromising the airway and causing distress for the patient.

Choice D rationale:

Waiting for at least 3 minutes between suctioning attempts is too long and not clinically appropriate. This extended time may lead to increased secretion buildup and potential airway obstruction, especially in patients with excessive secretions or those who are critically ill.

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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. Proceed with the suctioning as planned. B. Report the findings to the healthcare provider. C. Clean the area with hydrogen peroxide before suctioning. D. Use an antiseptic solution to cleanse the stoma.

Correct Answer is B

Explanation

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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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?

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 suction a patient's tracheostomy tube and observes signs of infection around the stoma. What action should the nurse take?

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 client with a tracheostomy is at risk of developing tracheomalacia. Which statement by the client indicates a need for further education?

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?

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 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:

Which statement by the nurse regarding tracheostomy care is correct?

(Select all that apply). A nurse is gathering equipment for suctioning a tracheostomy tube. Which of the following items should the nurse include in the setup?