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An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which of the following actions by the student requires the RN to intervene?
- A. The student preoxygenates the patient for 1 minute before suctioning.
- B. The student puts on clean gloves and uses a sterile catheter to suction.
- C. The student inserts the catheter about 13 cm into the tracheostomy tube.
- D. The student applies suction for 10 seconds while withdrawing the catheter.
Correct Answer: B
Rationale: Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other student actions do not require intervention by the RN. Although the patient may not need 1 minute of preoxygenation, this would not be unsafe. Suctioning for 10 seconds is appropriate. The length of catheter that should be inserted depends on the length of the tracheostomy tube, but the range is 13-15 cm for most adult patients.
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The nurse is deflating the cuff of a tracheostomy tube to evaluate the patient's ability to swallow. Which of the following actions should the nurse implement?
- A. Clean the inner cannula of the tracheostomy tube before deflation.
- B. Deflate the cuff during the inhalation phase of the respiratory cycle.
- C. Suction the patient's mouth and trachea before deflation of the cuff.
- D. Insert exactly the same volume of air into the cuff during reinflation.
Correct Answer: C
Rationale: The patient's mouth and trachea should be suctioned before the cuff is deflated to prevent aspiration of oral secretions. The amount of air needed to inflate the cuff varies and is adjusted by measuring cuff pressure or using the minimal leak technique, not by measuring the volume of air removed from the cuff. The cuff is deflated during patient exhalation so that secretions will be forced into the mouth rather than aspirated. There is no need to clean the inner cannula before cuff deflation.
The nurse is caring for a patient with a tracheostomy who has a new prescription for a fenestrated tracheostomy tube. Which of the following actions should be included in the plan of care?
- A. Leave the tracheostomy inner cannula inserted at all times.
- B. Place the decannulation cap in the tube before cuff deflation.
- C. Assess the ability to swallow before using the fenestrated tube.
- D. Inflate the tracheostomy cuff during use of the fenestrated tube.
Correct Answer: C
Rationale: Because the cuff is deflated when using a fenestrated tube, the patient's risk for aspiration should be assessed before changing to a fenestrated tracheostomy tube. The decannulation cap is never inserted before cuff deflation because to do so would obstruct the patient's airway. The cuff is deflated and the inner cannula removed to allow air to flow across the patient's vocal cords when using a fenestrated tube.
The nurse is caring for a patient with an uncuffed tracheostomy tube who coughs violently during suctioning and dislodges the tracheostomy tube. Which of the following actions should the nurse take first?
- A. Insert the obturator and attempt to reinsert the tracheostomy tube.
- B. Position the patient in an upright position with the neck extended.
- C. Assess the patient's oxygen saturation and notify the health care provider.
- D. Ventilate the patient with a manual bag until the health care provider arrives.
Correct Answer: A
Rationale: The first action should be to attempt to reinsert the tracheostomy tube to maintain the patient's airway. Assessing the patient's oxygenation is an important action, but it is not the most appropriate first action in this situation. Covering the stoma with a dressing and manually ventilating the patient may be an appropriate action if the nurse is unable to reinsert the tracheostomy tube. The patient should be placed in a semi-Fowler's position if reinsertion of the tracheostomy tube is not successful.
The nurse is teaching a patient with allergic rhinitis about management of the condition. Which of the following information should the nurse include in the teaching plan?
- A. Over-the-counter (OTC) antihistamines cause sedation, so prescription antihistamines are usually ordered.
- B. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use
- C. Use of oral antihistamines for a few weeks before the allergy season may prevent reactions.
- D. Identification and avoidance of environmental triggers are the best ways to avoid symptoms.
Correct Answer: D
Rationale: The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Nonsedating antihistamines are available OTC.
The nurse is caring for a patient with a tracheostomy tube and is inflating the cuff to the appropriate level. Which of the following actions is best for the nurse to implement?
- A. Check the pilot balloon after inflation to ensure that it is firm.
- B. Use a manometer to ensure cuff pressure is at an appropriate level.
- C. Check the amount of cuff pressure ordered by the health care provider.
- D. Fill the balloon until minimal air leakage around the cuff is auscultated.
Correct Answer: B
Rationale: Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg or lower will avoid compression of the tracheal capillaries. A firm pilot balloon indicates that the cuff is inflated but does not assess for over-inflation. A health care provider's order is not required to determine safe cuff pressure. A minimal leak technique is an alternate means for cuff inflation, but this technique does allow a small air leak around the cuff and increases the risk for aspiration.