What is the appropriate action when placing a cap on a tracheostomy tube with an inflated cuff?
Remove the tracheostomy tube completely before placing the cap.
Place the cap on the trach without deflating the cuff.
Deflate the cuff before placing the cap on the trach.
Place the cap on the trach with the cuff inflated.
The Correct Answer is C
A. Removing the tracheostomy tube completely is unnecessary and unsafe when capping.
B. Placing the cap without deflating the cuff will block airflow because the inflated cuff seals the airway.
C. Deflating the cuff before capping allows airflow around the tube, enabling the patient to breathe through the upper airway, which is necessary when using a trach cap.
D. Capping with the cuff inflated prevents air passage through the upper airway and may cause respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. An elevated heart rate can be a sign of hypovolemia or stress response but is not the most reliable indicator of adequate fluid resuscitation.
B. Serum hemoglobin levels may remain elevated due to hemoconcentration and are not the best indicator of resuscitation effectiveness.
C. Urine output greater than 0.5 mL/kg/hr is the most reliable and practical indicator of adequate fluid resuscitation in burn clients. It reflects renal perfusion and overall circulatory status.
D. Clear breath sounds are important but do not directly reflect the effectiveness of fluid resuscitation.
Correct Answer is D
Explanation
A. Blackened dead skin (eschar) is indicative of a full-thickness (third-degree) burn, not a first-degree burn.
B. Blistering suggests a partial-thickness (second-degree) burn, often caused by more intense heat or flame exposure.
C. Excessive scarring typically results from deeper burns, such as second- or third-degree burns, not superficial ones.
D. A sunburn is a classic example of a first-degree burn, which affects only the epidermis and presents with redness, pain, and mild swelling but no blisters or scarring.
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