After morning care, the nurse prepares for tracheostomy care. Which action will the nurse take? Select all that apply.

Create a sterile field.

Change trach ties if soiled.

Remove old dressings and excess secretions.

Suction the tracheostomy tube after the trach care.

Clean the inner cannula with full-strength hydrogen peroxide.

Answer and Explanation

Correct Answer : A,B,C

A. Tracheostomy care requires a sterile technique to prevent infection, as the trachea is a direct airway into the lungs. A sterile field is essential before cleaning and handling the trach tube.

B. Trach ties that are wet or soiled can harbor bacteria, cause skin breakdown, or compromise tube stability. Changing them maintains airway security and hygiene.

C. Removing old dressings and secretions prevents infection, keeps the skin clean, and prepares the site for new sterile dressings.

D. Suctioning is typically done before tracheostomy care to clear secretions, allowing the nurse to clean the site without obstruction or contamination. Suctioning after care is only done if secretions accumulate again.

E. Full-strength hydrogen peroxide is too harsh and can damage tissue. The inner cannula should be cleaned with sterile saline or a diluted, safe solution to remove secretions without causing chemical injury.

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Correct Answer is D

Explanation

A. A 21-year-old with confusion is usually classified as red (immediate priority) in mass casualty triage. Confusion may indicate hypoxia, shock, traumatic brain injury, or internal bleeding, all of which require rapid intervention to prevent death. This patient is potentially salvageable with prompt care.

B. A 23-year-old with an open femur fracture is generally classified as yellow (delayed priority). Open fractures are serious but not immediately life-threatening if the patient is hemodynamically stable. This patient can safely wait for treatment after more critical cases have been addressed.

C. A 26-year-old with uncontrollable anxiety but no physiologic compromise is considered green (minor/walking wounded). These patients may require psychological support, reassurance, and minor interventions but do not need immediate medical resources.

D. A 29-year-old with full-thickness extremity burns is assigned a black tag (expectant) in a mass casualty situation. Black-tagged patients have injuries incompatible with survival or require resources unlikely to save them in the current situation. Full-thickness burns covering a large area can lead to severe fluid loss, risk of infection and sepsis, impaired thermoregulation, and airway compromise if inhalation injury is present. In a resource-limited, mass casualty setting, these patients are unlikely to survive despite maximal intervention, so care is focused on comfort measures while resources are prioritized for salvageable patients.

A. Inward displacement of a rib section during inspiration B. Continuous outward bulging of a rib section throughout breathing C. Shift of mediastinal structures to affected side during inspiration D. Deep, inspiratory stridor during inspiration

Correct Answer is A

Explanation

A. Inward displacement of a rib section during inspirationis correct because flail chest occurs when two or more adjacent ribs are fractured in two or more places, creating a free-floating segment of the chest wall. This segment moves paradoxically, meaning it moves inward during inspiration and outward during expiration, which is the hallmark sign of flail chest. This paradoxical motion impairs ventilation and can lead to respiratory compromise.

B. Continuous outward bulging of a rib section throughout breathingis incorrect because flail chest is defined by paradoxical motion, not constant outward movement. Continuous outward bulging may suggest other chest wall deformities or localized swelling but is not diagnostic of flail chest.

C. Shift of mediastinal structures to affected side during inspirationis incorrect because mediastinal shiftoccurs in tension pneumothorax, not flail chest. In tension pneumothorax, air accumulates in the pleural space, pushing the heart and mediastinum toward the unaffected side, compromising circulation.

D. Deep, inspiratory stridor during inspirationis incorrect because stridor is an upper airway obstruction sign, not a characteristic of flail chest. Flail chest primarily affects ventilation mechanicsand causes paradoxical chest wall movement rather than airway noise.

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