A nurse is caring for a client who has a new tracheostomy. Which of the following actions should the nurse take when suctioning the client's tracheostomy?

Set the suction source at 220 mm Hg.

Repeat suctioning as needed up to five times.

Hyperventilate the client with 100% oxygen before suctioning.

Suction for 20 seconds with each pass.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Set the suction source at 220 mm Hg: This pressure is excessively high and can damage tracheal mucosa. Recommended suction pressure for an adult tracheostomy is typically 80–120 mm Hg to minimize tissue trauma while effectively clearing secretions.

B. Repeat suctioning as needed up to five times: Frequent suction passes increase the risk of hypoxia and mucosal injury. Generally, suctioning should be limited to a maximum of three passes per session, allowing adequate recovery and reoxygenation between attempts.

C. Hyperventilate the client with 100% oxygen before suctioning: Preoxygenating helps prevent hypoxemia during suctioning by increasing oxygen reserves. This is a standard safety measure, especially in clients with artificial airways, to maintain oxygenation during the procedure.

D. Suction for 20 seconds with each pass: Prolonged suctioning increases the risk of hypoxia, arrhythmias, and airway trauma. Each suction pass should be limited to 10–15 seconds for adults to reduce complications and promote safety.

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Correct Answer is D

Explanation

Rationale:

A. "You will need to change the IV dressing site once per week.": Central line dressings for TPN are typically changed every 48–72 hours for gauze or every 5–7 days for transparent dressings, or sooner if the dressing becomes damp, loose, or soiled, to reduce infection risk.

B. "You will need to warm the solution in the microwave before administration.": TPN solutions should never be microwaved due to the risk of uneven heating and nutrient degradation. They should be administered at room temperature.

C. "You will need to weigh the client twice per week.": Clients receiving TPN require daily weights to monitor fluid balance, nutritional status, and detect fluid retention or dehydration promptly. Twice-weekly measurements are insufficient for close monitoring.

D. "You will need to monitor the client's electrolytes daily.": TPN can cause rapid changes in fluid and electrolyte balance, so daily electrolyte monitoring allows timely adjustments to prevent complications such as hypo- or hypernatremia, hypokalemia, and metabolic imbalances.

A. "I will use an interpreter when providing client teaching." B. "I will use a communication board to assess the client's needs." C. "I will provide written instructions for the client in 8-point font." D. "I will use indirect lighting in the client's room."

Correct Answer is B

Explanation

Rationale:

A. "I will use an interpreter when providing client teaching.": An interpreter is useful for clients with language barriers. Expressive aphasia affects speech production, not comprehension, so an interpreter would not address the main communication challenge.

B. "I will use a communication board to assess the client's needs.": A communication board allows the client to point to words, pictures, or symbols to express thoughts and needs without relying on verbal speech. This is an effective method for facilitating communication with expressive aphasia.

C. "I will provide written instructions for the client in 8-point font.": Written instructions can help if reading skills are intact, but 8-point font is too small for easy readability, especially for clients who may also have vision changes. Larger, clear print is recommended.

D. "I will use indirect lighting in the client's room.": Lighting preferences may improve comfort, but they do not address the core communication difficulty caused by expressive aphasia. This intervention is unrelated to improving the client-nurse communication.

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Body System	Findings
Integumentary	Skin feels cool to the touch. Capillary refill 3 seconds in left foot Dressing on left hand shows small amount of moisture through gauze.
Vital Signs	Blood pressure 102/50 mm Hg Temperature 35.8° C (96.4° F) Respiratory rate 20/min
Genitourinary	Output of 25 mL dark amber urine through catheter

A nurse is caring for a client who has a new tracheostomy. Which of the following actions should the nurse take when suctioning the client's tracheostomy?

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