The nurse performing tracheostomy care will:
raise the head of the bed to high Fowler's position
remove the inner cannula with the ungloved hand
suction tracheostomy before beginning care
clean cannula with gauze and replace and lock
Correct Answer : A,C
A. Raise the head of the bed to high Fowler's position: This promotes optimal lung expansion and drainage, reduces aspiration risk, and facilitates easier tracheostomy care.
B. Remove the inner cannula with the ungloved hand: Sterile technique is required when handling the inner cannula to prevent infection.
C. Suction tracheostomy before beginning care: Suctioning clears secretions and ensures better visibility for care, reducing the risk of aspiration during the procedure.
D. Clean cannula with gauze and replace and lock: The inner cannula should be cleaned per protocol using sterile saline and replaced securely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
A. Incomplete expirations: Age-related decreased lung elasticity impairs full expiration, trapping air in the lungs.
B. Decreased oxygen saturation: Age-related changes in lung tissue reduce gas exchange efficiency.
C. Impaired cilia: Decreased ciliary function reduces the ability to clear mucus and pathogens from the airway.
D. Increased elasticity in thorax and respiratory tissues: Elasticity decreases with aging, reducing lung compliance.
Correct Answer is C
Explanation
A) Milk the chest tube to dislodge any clots in the tubing that may be occluding it. Milking the chest tube is not recommended as it can create excessive negative pressure and damage lung tissue.
B) Notify the provider. This is not the first intervention. The nurse should assess the suction regulator and connections before notifying the provider.
C) Verify that the suction regulator is on. Lack of bubbling often indicates that the suction regulator is off or not functioning correctly. The nurse should first ensure that the regulator is turned on and properly connected.
D) Continue to monitor the client because this is an expected finding. Bubbling should be present in the suction control chamber if suction is applied; therefore, this finding requires immediate assessment.
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