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) Milk the chest tube to dislodge any clots in the tubing that may be occluding it. Milking the chest tube is not recommended as it can create excessive negative pressure and damage lung tissue.
B) Notify the provider. This is not the first intervention. The nurse should assess the suction regulator and connections before notifying the provider.
C) Verify that the suction regulator is on. Lack of bubbling often indicates that the suction regulator is off or not functioning correctly. The nurse should first ensure that the regulator is turned on and properly connected.
D) Continue to monitor the client because this is an expected finding. Bubbling should be present in the suction control chamber if suction is applied; therefore, this finding requires immediate assessment.

A. Continue to monitor the client. B. Clamp the chest tube near the water seal. C. Reposition the client and recheck the chamber. D. Add water to the chamber.

Correct Answer is A

Explanation

A. Continue to monitor the client: A rise in the water seal with inspiration and fall during expiration (tidaling) is normal in a functioning chest tube system and indicates proper lung expansion.
B. Clamp the chest tube near the water seal: Clamping the tube can cause tension pneumothorax and is not appropriate unless specifically instructed by a provider.
C. Reposition the client and recheck the chamber: Repositioning is unnecessary unless there are signs of obstruction or complications.
D. Add water to the chamber: Water addition is only required if the water level falls below the recommended amount, not in response to normal tidaling.

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The nurse performing tracheostomy care will:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking the suction control chamber of a client's chest tube and notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following should the nurse do after noticing a rise in the water seal with client inspiration?

Correct Answer is A

Explanation

Which is a function of the respiratory system?

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