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.

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

Explanation

Choice A rationale:

Cleaning the stoma with hydrogen peroxide (Choice A) is not recommended for tracheostomy care. Hydrogen peroxide can be irritating and damaging to the tissues. Normal saline solution should be used to clean the stoma.

Choice B rationale:

Changing the ties or straps every 4 hours (Choice B) is not necessary unless they are soiled or loose. Frequent changes may irritate the skin and increase the risk of infection. Straps should be changed only when needed.

Choice C rationale:

Inspecting the stoma for signs of infection (Choice C) is a crucial step in tracheostomy care. Signs of infection may include redness, swelling, discharge, or foul odor. Prompt identification and treatment of infection are essential to prevent complications.

Choice E rationale:

Applying a new dressing around the stoma and securing it with tape (Choice E) is essential after tracheostomy care to maintain cleanliness and protect the stoma. Proper dressing helps prevent infection and skin breakdown.

Suctioning a tracheostomy tube is a sterile, invasive technique that requires a nurse or a respiratory therapist. It is done to remove secretions from the tube and prevent obstruction, infection, or hypoxia. The steps of suctioning a tracheostomy tube are:

A. Every 2 to 4 hours. B. Every 4 to 6 hours. C. Every 6 to 8 hours. D. Every 8 to 12 hours. E. Every 12 to 24 hours.

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.

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Which statement by the nurse regarding tracheostomy care is correct?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Select all the appropriate steps a nurse should take during tracheostomy care.

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

Explanation

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

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

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?

A nurse is caring for a patient with a tracheostomy. The patient suddenly develops bright red bleeding from the tracheostomy stoma, pulsation of the tracheostomy tube in synchrony with the heartbeat, hypotension, and tachycardia. What should the nurse do first?

(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?

A nurse is providing care for a patient with a tracheostomy tube. What type of tracheostomy tube would be most suitable for a patient who requires mechanical ventilation or has a high risk of aspiration?

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?

Which of the following patients would require a higher suction pressure during tracheostomy tube suctioning?

(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?