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 A

Explanation

Choice A rationale:

A cuffed tracheostomy tube is most suitable for a patient who requires mechanical ventilation or has a high risk of aspiration. The cuff is inflated to create a seal between the trachea and the tube, preventing aspiration of oral secretions or gastric contents into the airway. This is crucial for patients on mechanical ventilation to ensure effective ventilation and prevent complications like ventilator-associated pneumonia.

Choice B rationale:

Uncuffed tracheostomy tubes do not have an inflatable cuff, making them unsuitable for patients who require mechanical ventilation or have a high risk of aspiration. They are more appropriate for patients who can protect their own airway and have minimal risk of aspiration.

Choice C rationale:

Fenestrated tracheostomy tubes have an opening or fenestration on the tube that allows airflow through the upper airway, bypassing the tracheostomy tube. These tubes are used for patients who are weaning off mechanical ventilation and require speech therapy. They are not the most suitable choice for patients who need mechanical ventilation or have a high aspiration risk.

Choice D rationale:

Double-lumen tracheostomy tubes have two separate tubes, which can be used for independent lung ventilation in certain situations. They are not specifically designed for patients requiring mechanical ventilation or with a high risk of aspiration.

Choice E rationale:

Metal tracheostomy tubes are not commonly used for patients requiring mechanical ventilation or with a high risk of aspiration. Metal tubes may be used in certain cases, but they are not the most suitable choice for this patient population.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a patient with a tracheostomy tube. What type of tracheostomy tube would be most suitable for a patient who requires mechanical ventilation or has a high risk of aspiration?

Correct Answer is A

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

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 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 nurse is suctioning a tracheostomy tube and wants to ensure proper oxygenation between attempts. How long should the nurse wait between each suctioning attempt?

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?