Which statement by the nurse regarding tracheostomy care is correct?

"I will monitor the cuff pressure to keep it between 20 to 25 cm H2O.".

"The fenestration should remain open at all times.".

"The inner cannula is only used when the patient requires mechanical ventilation.".

"A fenestrated tube is used for patients with a low risk of aspiration.".

"Metal tracheostomy tubes are commonly used for long-term ventilation.".

Answer and Explanation

The Correct Answer is D

Choice D rationale:

This statement is correct. A fenestrated tracheostomy tube is designed for patients with a low risk of aspiration and are weaning from mechanical ventilation. The fenestration allows the patient to breathe through the upper airway, promoting speech and facilitating the weaning process. The fenestration can be temporarily occluded to assess the patient's readiness for decannulation.

Choice A rationale:

Monitoring cuff pressure is essential, but the suggested range of 20 to 25 cm H2O is not universally applicable. The appropriate cuff pressure range may vary depending on the patient's condition, and it should be individualized based on the patient's needs.

Choice B rationale:

Keeping the fenestration open at all times is not accurate. The fenestration can be open to allow airflow during weaning and speech therapy, but it can be temporarily occluded when assessing the patient's ability to breathe without the tube.

Choice C rationale:

The inner cannula is not solely used during mechanical ventilation. It is also used for routine cleaning and maintenance of the tracheostomy tube, regardless of the patient's ventilation status.

Choice E rationale:

Metal tracheostomy tubes are not commonly used for long-term ventilation. They are mostly used in specific situations where a plastic tube may not be suitable, such as when there is a risk of tube distortion or damage. Plastic tubes are more commonly used for long-term ventilation due to their availability, flexibility, and ease of use.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

Performing tracheostomy care every 2 to 4 hours would be too frequent for most patients and may cause unnecessary disruption and discomfort. This interval is not the recommended standard of care.

Choice B rationale:

Tracheostomy care every 4 to 6 hours strikes a balance between maintaining airway hygiene and minimizing excessive handling of the tracheostomy site, reducing the risk of complications such as infection or irritation.

Choice C rationale:

Waiting to perform tracheostomy care every 6 to 8 hours may increase the risk of mucus buildup and potential complications, especially in patients with high secretions or respiratory issues.

Choice D rationale:

Extending the interval to every 8 to 12 hours may lead to inadequate airway clearance and increased risk of complications in patients who require more frequent care.

Choice E rationale:

Waiting to perform tracheostomy care every 12 to 24 hours is too infrequent for most patients and may not be sufficient to maintain a patent airway and prevent complications.

A. Apply continuous suction while inserting the catheter. B. Rinse the catheter with sterile saline between each attempt. C. Limit suctioning attempts to three per session. D. Withdraw the catheter gently while applying suction.

Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale:

Applying continuous suction while inserting the catheter can cause trauma to the tracheal mucosa and increase the risk of bleeding and infection.

Choice B rationale:

Rinsing the catheter with sterile saline between each suctioning attempt helps maintain aseptic technique, preventing the introduction of microorganisms into the airway.

Choice C rationale:

Limiting suctioning attempts to three per session reduces the risk of hypoxia and mucosal damage, ensuring adequate oxygenation and preventing complications.

Choice D rationale:

Withdrawing the catheter gently while applying suction prevents damage to the tracheal walls and minimizes the risk of bleeding.

Choice E rationale:

Hyperoxygenating the patient before and after suctioning helps prevent hypoxemia during the procedure, reducing the risk of complications and ensuring adequate oxygenation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which statement by the nurse regarding tracheostomy care is correct?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform tracheostomy care for a patient. What is the recommended interval for performing tracheostomy care?

Correct Answer is B

Explanation

(Select all that apply). A nurse is suctioning a tracheostomy tube for a patient. Which of the following actions are correct during the suctioning process?

Correct Answer is ["B","C","D","E"]

Explanation

(Select all that apply). A nurse is gathering equipment for suctioning a tracheostomy tube. Which of the following items should the nurse include in the setup?

A nurse is preparing to suction a tracheostomy tube for a patient. What position should the nurse place the patient in?

A client with a tracheostomy tube is ready to wean from mechanical ventilation and also requires speech therapy. What type of tracheostomy tube would be the most appropriate choice for this client?

A nurse is preparing to suction a client's tracheostomy tube. Which step should the nurse perform first during the suctioning procedure?

A nurse is about to insert the suction catheter into the patient's tracheostomy tube. The patient says, "I'm feeling anxious about this.”What would be the nurse's appropriate response?

A client with a tracheostomy is at risk of developing tracheomalacia. Which statement by the client indicates a need for further education?

A nurse is educating a patient with a tracheostomy on communication methods. Which information should the nurse include?

A nurse is providing care for a patient with a tracheostomy who complains of increased coughing, difficulty breathing, and stridor. The nurse assesses that the tracheal lumen has narrowed due to scar formation. Which statement by the nurse is appropriate?