Nokea
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?
- A. Applying suction while inserting the catheter
- B. Preoxygenating the client prior to suctioning
- C. Suctioning for a total of three times
- D. Suctioning for only 10 to 15 seconds each time
Correct Answer: A
Rationale: Suction should only be applied while withdrawing the catheter. The other actions are appropriate.
You may also like to solve these questions
A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.)
- A. Create a communication system.
- B. Don't go out in public alone.
- C. Try loose-fitting shirts with collars.
- D. Wear fashionable scarves.
Correct Answer: A,C,E
Rationale: The client with a tracheostomy may be shy and hesitant to go out in public. The client should have a sound method of communication. The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good advice.
A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Applying lip balm for the client.
- B. Ensuring the humidification provided is adequate.
- C. Performing oral care with alcohol-based mouthwash.
- D. Reminding the client to cough and deep breathe often.
- E. Suctioning excess secretions through the tracheostomy.
Correct Answer: A,D
Rationale: The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care should be accomplished with normal saline, not products that dry the mouth. Ensuring humidity is adequate and suctioning through the tracheostomy are nursing functions.
A client has a tracheostomy tube in place. The nurse is monitoring for complications associated with the tracheostomy and notes that it takes increased pressure to maintain a seal with the tracheostomy tube cuff. What action by the nurse is most appropriate?
- A. Measure tracheostomy cuff pressures.
- B. Elevate the head of the bed.
- C. Place the client on NPO status.
- D. Request that the client have a swallow study.
Correct Answer: B
Rationale: Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This may be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not correct this situation.
A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?
- A. 24%
- B. 21%
- C. 33%
- D. 31%
Correct Answer: B
Rationale: Room air is 21% oxygen.
A client has a tracheostomy that is 2 days old. Upon assessment, the nurse note the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority?
- A. Assess the clients oxygen saturation.
- B. Notify the Rapid Response Team.
- C. Oxygenate the client with a bag-valve-mask.
- D. Palpate the skin of the upper chest.
Correct Answer: A
Rationale: This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the clients oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.