1.
What is the best nursing intervention you need to perform when you notice that the tracheostomy site of your patient has yellowish discharges?
Correct Answer
C. Practice standard precaution, perform tracheostomy care, and report the signs of infection.
Explanation
When a tracheostomy site has yellowish discharges, it is important to practice standard precautions to prevent the spread of infection. Performing tracheostomy care helps to maintain cleanliness and prevent further complications. Additionally, reporting the signs of infection is crucial as it allows for timely intervention and appropriate treatment. This answer encompasses all these necessary interventions to ensure the well-being of the patient.
2.
What is the most important nursing procedure to perform prior to tracheostomy care to minimize the risk of infection?
Correct Answer
B. Hand washing
Explanation
Hand washing is the most important nursing procedure to perform prior to tracheostomy care to minimize the risk of infection. This is because hand washing helps to remove microorganisms from the hands, reducing the chance of introducing them into the tracheostomy site. Proper hand hygiene is crucial in healthcare settings to prevent the spread of infections and maintain patient safety. Using curtains, sterile gloves, and proper waste disposal are also important procedures, but hand washing takes precedence in this context.
3.
A tracheostomy tube is inserted in a patient who is in respiratory distress as a result of pneumonia. The family asks why the tube is inserted. What should the nurse include when explaining to the patient and family? The purpose of a tracheostomy tube is to:
Correct Answer
D. Provide more controlled ventilation and ease removal of secretions the client is unable to handle.
Explanation
This is the purpose of a tracheostomy. The client may become less anxious when she is no longer hypoxic. However, relief of anxiety is not the purpose of a tracheostomy tube.
4.
Rinse the suction tubing by dipping its end into the sterile water bottle and applying suction until the solution has rinsed the tubing through.
Correct Answer
A. True
Explanation
The correct answer is true because rinsing the suction tubing by dipping its end into the sterile water bottle and applying suction until the solution has rinsed the tubing through is an appropriate and effective method of cleaning the tubing. This process helps to remove any debris or residue that may be present in the tubing, ensuring that it is clean and ready for use.
5.
Select all that apply.What emergency equipment is required at the bedside for the patient with a tracheostomy
Correct Answer(s)
A. Bag Valve Mask
B. Suction equipment
C. Oxygen
Explanation
The correct answer is Bag Valve Mask, Suction equipment, and Oxygen. These emergency equipment are necessary for a patient with a tracheostomy. A Bag Valve Mask is used for providing positive pressure ventilation in case of respiratory distress. Suction equipment is required to clear any secretions or blockages from the tracheostomy tube. Oxygen is essential for maintaining adequate oxygenation in the patient. These equipment ensure that the patient's airway is protected and they can breathe properly in case of any emergency.
6.
An adult is about to have a tracheostomy performed. Which action is of the highest priority for the nurse before the procedure is done?
Correct Answer
A. Establishing means of postoperative communication.
Explanation
A tracheostomy makes a client unable to speak. Other means of communication will be necessary.
7.
Select all that apply.
What are the tracheostomy complications?
Correct Answer(s)
A. Infection
B. Pneumonia
C. Hemorrhage
D. Subcutaneous empHysema
Explanation
The correct answer is infection, pneumonia, hemorrhage, and subcutaneous emphysema. Tracheostomy is a surgical procedure that involves creating an opening in the neck to access the trachea. Complications of tracheostomy can include infection, which can occur at the site of the incision or in the respiratory tract. Pneumonia can also occur due to the introduction of bacteria into the lungs during the procedure. Hemorrhage is a potential complication due to damage to blood vessels during the surgery. Subcutaneous emphysema can occur if air leaks into the tissues surrounding the tracheostomy site, causing swelling and discomfort.
8.
The recommended pressure for wall suction in an adult is 100-120 mmHg?
Correct Answer
A. True
Explanation
The recommended pressure for wall suction in an adult is 100-120 mmHg. This range of pressure is considered safe and effective for removing secretions and maintaining airway patency. Suction pressures that are too low may not effectively clear secretions, while pressures that are too high can cause tissue damage or bleeding. Therefore, maintaining the recommended pressure range is crucial for proper suctioning in adult patients.
9.
Hydration is an important factor to consider when assessing when a client needs to be.. (what?)
Correct Answer
C. Suctioned
Explanation
When assessing the need for a client to be suctioned, hydration is an important factor to consider. Adequate hydration helps to thin and loosen respiratory secretions, making them easier to remove through suctioning. If a client is dehydrated, their secretions may become thick and difficult to clear, increasing the need for suctioning. Therefore, assessing hydration levels is crucial in determining if suctioning is necessary for a client.
10.
What is the maximum diameter of suction catheter you will use to perform tracheostomy suctioning?
Correct Answer
C. No larger than 1/2 diameter of artificial airway d/t atelectasis risk
Explanation
The correct answer is "No larger than 1/2 diameter of artificial airway d/t atelectasis risk". This means that when performing tracheostomy suctioning, the maximum diameter of the suction catheter should not exceed half the diameter of the artificial airway. This is because using a larger catheter can increase the risk of atelectasis, which is the collapse or closure of the lung. Therefore, it is important to use a catheter that is appropriate in size to minimize the risk of complications during tracheostomy suctioning.
11.
Prior to and after performing tracheostomy care to a client, we are doing what with oxygen?
Correct Answer
A. Hyperoxygenation
Explanation
Prior to and after performing tracheostomy care, it is important to hyperoxygenate the client. This involves providing an increased level of oxygen to the client to ensure that their oxygen levels are optimized. Hyperoxygenation helps to prevent hypoxia, which is a condition characterized by low oxygen levels in the body. By hyperoxygenating the client, we can ensure that they have an adequate oxygen supply during and after the tracheostomy care procedure.
12.
When tracheostomy suctioning, remove the catheter from the sleeve and introduce the catheter to about one-third of its length or approximately 10–15 cm or until the patient coughs. If resistance is felt, withdraw the catheter approximately 1 cm before applying suction by placing the thumb over the suction port control and slowly withdrawing the remainder of the catheter.
Correct Answer
A. True
Explanation
When performing tracheostomy suctioning, it is important to remove the catheter from the sleeve and insert it to about one-third of its length or approximately 10-15 cm, or until the patient coughs. If resistance is encountered, the catheter should be withdrawn approximately 1 cm before applying suction by placing the thumb over the suction port control and slowly withdrawing the rest of the catheter. This ensures that the suctioning is done effectively and safely.
13.
A nurse is caring for a patient with a tracheostomy. The nurse notes that the patient has gurgling sounds coming from the trach site, he is breathing rapidly, and he is trying to cough. Which action should the nurse perform next?
Correct Answer
A. Suction the opening and the trach tubing
Explanation
The nurse should suction the opening and the trach tubing. The patient's gurgling sounds indicate that there may be secretions blocking the airway, which can be cleared by suctioning. The patient's rapid breathing and attempts to cough further suggest that there is an obstruction that needs to be addressed. Suctioning the trach site and tubing will help remove any secretions and improve the patient's breathing. Assessing lung sounds, replacing the trach tubing with an Ambu-bag, and checking capillary refill are important actions but are not the immediate priority in this situation.
14.
Excessive coughing cannot cause tracheostomy tube displacement.
Correct Answer
B. False
Explanation
Excessive coughing can potentially cause tracheostomy tube displacement. The forceful coughing can create pressure and movement in the airway, which may result in the tube becoming dislodged or shifted from its intended position. Therefore, the statement is false.
15.
What is the normal tracheostomy cuff pressure?
Correct Answer
B. 20-25 mmHg
Explanation
The normal tracheostomy cuff pressure is 20-25 mmHg. This pressure range is considered optimal to maintain an adequate seal around the tracheostomy tube while minimizing the risk of complications such as pressure ulcers or tracheal damage. Higher pressures may cause ischemia or necrosis of the tracheal mucosa, while lower pressures may lead to air leakage and aspiration. Therefore, maintaining a cuff pressure within the recommended range is crucial for patient safety and comfort.