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Which equipment is necessary to perform tracheostomy care on a client? Select all that apply.

A.

Endotracheal stabilization device

B.

Sterile tracheostomy care kit

C.

Sterile normal saline

D.

Sterile and clean gloves

E.

Disposable inner cannula if client has one

Answer and Explanation

Correct Answer : B,C,D,E

Rationale:
A. An endotracheal stabilization device is specifically designed to secure an endotracheal tube, which is inserted through the mouth or nose into the trachea. It is not required for routine tracheostomy care because a tracheostomy tube is already secured via the neck plate and ties, making this equipment unnecessary.

B. A sterile tracheostomy care kit is essential for performing safe tracheostomy care. The kit contains all necessary sterile supplies, such as sterile gloves, suction catheters, sterile dressings, cotton-tipped applicators, and cleaning solutions. Using a sterile kit helps maintain aseptic technique, reduces the risk of infection, and ensures that the procedure is performed safely and efficiently.

C. Sterile normal saline is required to moisten dressings and clean the tracheostomy site. It is used to gently remove secretions, mucus, or crusting around the stoma and tube. Using sterile saline prevents the introduction of pathogens into the airway and protects the delicate mucosal tissue from irritation or infection.

D. Sterile and clean gloves are critical for infection prevention. Sterile gloves are used when handling the tracheostomy tube, inner cannula, or the stoma itself to prevent contamination. Clean gloves are used when handling non-sterile items, such as adjusting the ties or touching the patient’s skin away from the stoma. Proper glove use maintains aseptic technique and minimizes the risk of infection.

E. A disposable inner cannula, if the client has one, is necessary for removal, cleaning, or replacement. The inner cannula can accumulate mucus and secretions, which can obstruct airflow if not cleaned or replaced regularly. Using a disposable inner cannula allows for safe and efficient maintenance of airway patency.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

Rationale:

  • Gelatin – Clear Liquid
    Gelatin is considered a clear liquid because it is transparent at room temperature and leaves no residue in the gastrointestinal tract. It is easily digested and appropriate for clients transitioning from NPO status or recovering from GI procedures.

  • Popsicle – Clear Liquid
    Popsicles (without milk, pulp, or cream) are classified as clear liquids because they melt into a transparent fluid. They provide hydration and small amounts of sugar but do not stimulate significant digestive activity.
  • Tea – Clear Liquid
    Plain tea (without milk or cream) is a transparent liquid and is easily absorbed. Clear liquids must allow light to pass through and leave minimal digestive residue, which tea does.
  • Beef broth – Clear Liquid
    Broth is considered clear because it contains no solid particles and is transparent. It provides electrolytes and minimal protein while remaining easy to digest.
  • Cream soup – Full Liquid
    Cream soups are not transparent and contain milk or cream, making them thicker and more nutritionally substantial than clear liquids. Full liquids include items that are liquid at room temperature but may contain dairy or strained ingredients.
  • Ice cream – Full Liquid
    Ice cream is classified as a full liquid because it melts into liquid form at body temperature and contains milk, fat, and sugar. It provides more calories and nutrients than clear liquids but is not considered clear due to its opacity.

Correct Answer is B

Explanation

Rationale:
A. Stopping the enteral feedings and calling the healthcare provider is appropriate. The client is showing signs of possible aspiration or fluid overload—tachypnea, hypoxia, and bilateral crackles—which require immediate intervention to prevent further complications.

B. Lowering the head of the bed is contraindicated. A supine or low position increases the risk of aspiration, especially in a client receiving enteral feedings. Keeping the head elevated helps prevent gastric contents from entering the lungs and worsening respiratory compromise.

C. Administering oxygen via nasal cannula is appropriate to address hypoxia and improve oxygen saturation. Oxygen therapy is a supportive measure while further evaluation and interventions are initiated.

D. Placing the client in high Fowler’s position is correct. Elevating the head of the bed to 60–90 degrees helps reduce the risk of aspiration, improves lung expansion, and facilitates safer administration of enteral nutrition.

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