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

Clean the stoma with hydrogen peroxide.

Change the ties or straps every 4 hours.

Inspect the stoma for signs of infection.

Reinsert the inner cannula and lock it in place.

Apply a new dressing around the stoma and secure it with tape.

Answer and Explanation

Correct Answer : C,D,E

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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Correct Answer is B

Explanation

Choice A rationale:

A neonate with a tracheostomy tube would require lower suction pressure compared to an adult. Neonates have smaller and more delicate airways, making them more susceptible to damage from high suction pressures. Using lower suction pressures is essential to ensure the safety and well-being of the neonate.

Choice B rationale:

An adult with a tracheostomy tube may require higher suction pressure compared to other age groups. Adults generally have larger airways and more significant secretion production. Adequate suction pressure is necessary to effectively remove secretions and maintain airway patency.

Choice C rationale:

A child with a tracheostomy tube would typically require lower suction pressure than an adult. Children have smaller airways than adults, and using high suction pressures could cause harm and discomfort.

Choice D rationale:

An infant with a tracheostomy tube would require lower suction pressure compared to an adult. Infants have smaller airways and are more sensitive to changes in pressure. Using higher suction pressure could cause trauma to the delicate tissues in their airways.

A. Maintain proper cuff pressure. B. Progress to a deflated cuff or cuffless tube as soon as possible. C. Perform tracheal dilation or surgical intervention if needed. D. Use a small soft feeding tube instead of a nasogastric tube for tube feedings. E. Administer oxygen by mask to prevent hypoxemia.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale:

Maintaining proper cuff pressure prevents pressure-related injuries and potential tracheoesophageal fistula (TEF) formation.

Choice B rationale:

Progressing to a deflated cuff or cuffless tube reduces the risk of TEF by minimizing pressure on the tracheal tissues.

Choice C rationale:

Tracheal dilation or surgical intervention may be necessary if TEF has already developed but is not a preventive measure.

Choice D rationale:

Using a small soft feeding tube instead of a nasogastric tube for tube feedings reduces the risk of trauma to the tracheal tissues and lowers the risk of TEF formation.

Choice E rationale:

Administering oxygen by mask may be necessary for oxygenation, but it is not specifically related to preventing tracheoesophageal fistula formation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

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:

Correct Answer is ["A","B","D"]

Explanation

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

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 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?

(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?

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

(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?

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