The nurse performing tracheostomy care will:

raise the head of the bed to high Fowler's position

remove the inner cannula with the ungloved hand

suction tracheostomy before beginning care

clean cannula with gauze and replace and lock

Answer and Explanation

Correct Answer : A,C

A. Raise the head of the bed to high Fowler's position: This promotes optimal lung expansion and drainage, reduces aspiration risk, and facilitates easier tracheostomy care.
B. Remove the inner cannula with the ungloved hand: Sterile technique is required when handling the inner cannula to prevent infection.
C. Suction tracheostomy before beginning care: Suctioning clears secretions and ensures better visibility for care, reducing the risk of aspiration during the procedure.
D. Clean cannula with gauze and replace and lock: The inner cannula should be cleaned per protocol using sterile saline and replaced securely.

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Correct Answer is C

Explanation

A. Examining the character of the sputum: While monitoring secretions is important, it does not necessarily indicate the need for immediate suctioning.
B. Monitoring the rate of respirations: An increased respiratory rate can indicate distress but is not a definitive cue for suctioning.
C. Auscultating the breath sounds: This helps identify the presence of secretions or airway obstruction and is a primary indicator for suctioning.
D. Determining the last time the patient was suctioned: Suctioning should be based on clinical need rather than a routine schedule.

A. use a 14-Fr catheter B. use suction pressure between 120 and 160 mm Hg C. use an 8-Fr catheter D. use the catheter to suction the mouth and nasopharynx

Correct Answer is A

Explanation

A. Use a 14-Fr catheter: This is the appropriate size for suctioning an adult to effectively remove thick secretions.
B. Use suction pressure between 120 and 160 mm Hg: This pressure is too high and may cause mucosal damage; 100 to 120 mm Hg is recommended for adults.
C. Use an 8-Fr catheter: This size is too small for effectively suctioning thick secretions in adults.
D. Use the catheter to suction the mouth and nasopharynx: Suctioning the mouth first contaminates the catheter, increasing the risk of infection in the nasopharynx.

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The nurse performing tracheostomy care will:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:

Correct Answer is C

Explanation

A nurse is nasopharyngeal suctioning an adult patient to remove thick secretions. The nurse will:

Correct Answer is A

Explanation

A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

The nurse performing tracheostomy care will:

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