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The nurse is caring for a patient with an endotracheal tube. What interventions will the nurse implement?
- A. Change or clean all respiratory therapy equipment every 24 hours.
- B. Turn and reposition the patient every 2 hours.
- C. Provide constant airway humidification.
- D. Encourage intake of fruits and vegetables.
- E. Elevate the head of the bed.
Correct Answer: B,C,E
Rationale: Nursing interventions for the patient with an endotracheal tube include turning and repositioning every 2 hours for maximal ventilation and lung expansion, constant airway humidification and elevation of the head of the bed to assist with ventilation. Equipment should be changed or cleaned at least every 8 hours. Patients with endotracheal tubes are allowed nothing by mouth (NPO). It is necessary to provide parenteral or enteral nourishment.
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A cannula is a device consisting of small tubes inserted into the nares and is the most common way to administer oxygen.
Correct Answer: nasal
Rationale: A nasal cannula is a device consisting of small tubes inserted into the nares and is the most common way to administer oxygen.
Which of the following is an appropriate nursing measure when performing tracheostomy care?
- A. Wear clean gloves.
- B. Insert the catheter without suction.
- C. Suction for 1 minute before removing the catheter.
- D. Place the used catheter in a plastic shield for later use.
Correct Answer: B
Rationale: Insertion of the suction catheter without suction reduces the probability of tissue injury. Sterile gloves should be used for tracheostomy care. Suctioning should be done for a maximum of 10 seconds at a time. A used catheter should be disposed of appropriately.
The wife of a patient with a cuffed tracheostomy asks why the cuff is inflated intermittently. What is the purpose of the inflated cuff?
- A. Prevent regurgitation after meals.
- B. Hold the trachea open until it is completely healed.
- C. Dilate the tracheal opening for passage of secretions.
- D. Prevent aspiration when eating.
Correct Answer: D
Rationale: The cuff is inflated to prevent aspiration while eating or when cleaning the tracheostomy tube.
What is the appropriate value for the Venturi mask? Oxygen delivery devices with percent of oxygen delivered
- A. 1-6 L/min = 24%-44% O2
- B. 5-8 L/min = 35%-55% O2
- C. 4-10 L/min = 24%-55% O2
- D. 6-12 L/min = 60%-90% O2
- E. 6-15 L/min = 70%-100% O2
Correct Answer: C
Rationale: Venturi mask delivers 4-10 L/min = 24%-55% O2, as per the table: Nasal cannula (1-6 L/min = 24%-44% O2), Simple face mask (5-8 L/min = 35%-55% O2), Venturi mask (4-10 L/min = 24%-55% O2), Partial rebreather mask (6-12 L/min = 60%-90% O2), Nonrebreather mask (6-15 L/min = 70%-100% O2).
When suctioning a tracheostomy suction may be applied for a maximum of ____ seconds at a time never longer.
Correct Answer: 10
Rationale: Suctioning should be done for a maximum of 10 seconds at a time. Prolonged suctioning depletes oxygen supply.