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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A) Trendelenburg. This position involves tilting the patient with the head lower than the body and can worsen respiratory distress.
B) Tripod. The tripod position maximizes lung expansion by allowing the diaphragm to move freely, improving oxygenation.
C) Supine. The supine position can impair lung expansion and worsen respiratory distress.
D) Low-Fowler's Position. This position may provide minimal respiratory relief but is not as effective as the tripod position.

A. be monitored for respiratory rate B. have the cuff pressure checked C. have the pharynx suctioned D. be administered extra oxygen

Correct Answer is C

Explanation

A. Be monitored for respiratory rate: Important for ongoing assessment but not directly related to the deflation process.
B. Have the cuff pressure checked: Necessary during care but not immediately before deflation.
C. Have the pharynx suctioned: Suctioning clears secretions that could be aspirated when the cuff is deflated.
D. Be administered extra oxygen: Beneficial but not a direct prerequisite for cuff deflation.

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The nurse performing tracheostomy care will:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing respiratory distress. Which of the following positions should the nurse assist the client into?

Correct Answer is B

Explanation

The nurse recognizes that, immediately before a tracheostomy cuff deflation, the patient should:

Correct Answer is C

Explanation

Your patient is breathing shallowly and seems irritable and restless. A nursing action that might help is to have him:

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