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

be monitored for respiratory rate

have the cuff pressure checked

have the pharynx suctioned

be administered extra oxygen

Answer and Explanation

The Correct Answer is C

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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Correct Answer is D

Explanation

A. Perform tracheostomy care for the client every 4 hr: Tracheostomy care is performed based on the assessment of the need for cleaning and secretion management rather than a fixed time schedule.
B. Place the client in a lateral recumbent position prior to tracheostomy care: This position does not facilitate optimal visualization of the tracheostomy site. The Fowler's or semi-Fowler's position is preferred.
C. Clean the tracheostomy stoma with a chlorhexidine solution: Chlorhexidine is too harsh for mucosal surfaces and can cause irritation. Normal saline is recommended for cleaning.
D. Preoxygenate the client for 10 seconds prior to tracheostomy care: Preoxygenation for at least 30 to 60 seconds is recommended to prevent hypoxia during suctioning.

A. examining the character of the sputum B. monitoring the rate of respirations. C. auscultating the breath sounds D. determining the last time the patient was suctioned

Correct Answer is C

Explanation

A. Examining the character of the sputum: While monitoring secretions is important, it does not necessarily indicate the need for immediate suctioning.
B. Monitoring the rate of respirations: An increased respiratory rate can indicate distress but is not a definitive cue for suctioning.
C. Auscultating the breath sounds: This helps identify the presence of secretions or airway obstruction and is a primary indicator for suctioning.
D. Determining the last time the patient was suctioned: Suctioning should be based on clinical need rather than a routine schedule.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:

Correct Answer is C

Explanation

A nurse performing oral suctioning on an adult patient should set the wall suction machine so that the suction pressure is between:

A nurse is reinforcing teaching with a newly licensed nurse about tracheostomy care for a toddler. Which of the following instructions should the nurse include in the teaching?

The nurse instructing the patient to perform forceful exhalation coughing would instruct the patient to take in:

The nurse caring for a patient with a disposable chest drainage system can promote effective tube function and patient safety by:

A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

The nurse clarifies that the cough mechanism is stimulated when:

The nurse takes into consideration that a pulse oximeter may not give an accurate reading if the patient is:

A nurse is reinforcing teaching with a client who has a prescription for home oxygen therapy. Which of the following instructions should the nurse include?