question

Tracheotomy

answer

the surgical incision into the trachea to create an airway.

question

Tracheostomy

answer

the tracheal stoma that results from a tracheotomy

question

Indications for tracheostomy

answer

acute airway obstruction. need for airway protection. laryngeal or facial trauma/burns. involvement in head or neck surgeries

question

Which complication is the result of constant pressure exerted by a tracheostomy cuff, causing tracheal dilation and erosion of cartilage?

answer

Tracheomalacia

question

How does the nurse define a tracheostomy to the patient?

answer

Opening in the trachea that enables breathing.

question

How does the nurse assess for subcutaneous emphysema: a potential complication associated with tracheostomy

answer

Inspecting and palpating for air under the skin.

question

assessment findings related to Tracheal Stenosis

answer

increased coughing, inability to expectorate secretions, and difficulty breathing

question

A patient returns from the operating room after having a tracheostomy. While assessing the patient, which observations made by the nurse warrant immediate notification of the provider?

answer

Skin is puffy at the neck area with a crackling sensation.

question

A patient was intubated for acute respiratory failure, and there is an endotracheal tube in place. Which nursing interventions are appropriate?

answer

Ensure that the oxygen is warmed and humidified. Suction the airway, then the mouth, and give oral care. Position the tubing so it does not pull on the airway. Apply suction only when withdrawing the suction catheter.

question

To prevent accidental decannulation of a tracheostomy tube, what does the nurse do?

answer

Secure the tube in place using ties or fabric fasteners.

question

A patient has a recent tracheostomy. What necessary equipment does the nurse ensure is kept at the bedside?

answer

Ambu bag, oxygen tubing, suction equipment, tracheostomy tube with obturator

question

A patient has a temporary tracheostomy following surgery to the neck area to remove a benign tumor. Which nursing intervention is performed to prevent obstruction of the tracheostomy tube?

answer

Provide tracheal suctioning when there are noisy respirations.

question

A patient sustained a serious crush injury to the neck and had a tracheostomy tube placed 3 days ago. As the nurse is performing tracheostomy care, the patient suddenly sneezes very forcefully and the tracheostomy tube falls out onto the bed linens. What does the nurse do?

answer

Quickly and gently replaced the tube with a clean cannula kept at the bedside.

question

Patients with a tracheostomy or endotracheal tube need suctioning. Which nursing interventions apply to proper suctioning technique?

answer

Preoxygenate the patient for at least 30 seconds before suctioning. Instruct the patient that they are going to be suctioned. Quickly insert the suction catheter until resistance is met.

question

What are possible complications that can occur with suctioning from an artificial airway?

answer

Infection. Hypoxia. Tissue Trauma. Vagal Stimulation. Bronchospasm.

question

While the nursing student changes a patient's tracheostomy dressing, the nurse observes the student using a pair of scissors to cut a 4 x 4 gauze pad to make a split dressing that will fit around the tracheostomy tube. What is the nurse's best action?

answer

Direct the student in the correct use of materials and explain the rationale.

question

The nurse is caring for a patient with a tracheostomy who has recently been transferred from the intensive care unit, but he has had no unusual occurrences related to the tracheostomy or his oxygenation status. What does the routine care for this patient include?

answer

Thorough respiratory assessment at least every 2 hours.

question

A patient with a tracheostomy is being discharged to home. In patient teaching, what does the nurse instruct the patient to do?

answer

Increase the humidity in the home.

question

A patient with a permanent tracheostomy is interested in developing an exercise regimen. Which activity does the nurse advise the patient to avoid?

answer

Swimming.

question

A patient with a tracheostomy who receives unnecessary suctioning can experience which complications?

answer

Bronchospasm. Mucosal Damage. Bleeding.

question

A patient who is breathing on his own has a fenestrated tracheostomy tube with a cuff. Which precaution must the nurse instruct the student about when caring for this patient?

answer

Always deflate the cuff before capping the tube with the decannulation cap.

question

A patient has a cuffed tracheostomy tube without a pressure relief valve. To prevent tissue damage of the tracheal mucosa, what does the nurse do?

answer

Assess and record cuff pressures each shift using minimal leak technique.

question

A patient with a tracheostomy tube is currently alert and cooperative but seems to be coughing more frequently and producing more secretions than usual. The nurse determines that there is a need for suctioning. Which nursing intervention does the nurse use to prevent hypoxia for this patient?

answer

Avoid prolonged suction time.

question

The nurse is suctioning the secretions from a patient's endotracheal tube. The patient demonstrates a vagal response by a drop in heart rate to 54/min and a drop in blood pressure to 90/50 mm Hg. After stopping suctioning, what is the nurse's priority action?

answer

Oxygenate with 100% oxygen and monitor the patient.

question

A patient with a tracheostomy is unable to speak. He is not in acute distress, but is gesturing and trying to communicate with the nurse. Which nursing intervention is the best approach to this situation?

answer

Ask questions that can be answered with a "yes" or "no" response.

question

Which clinical finding in a patient with a recent tracheostomy is the most serious and requires immediate intervention?

answer

Pulsating tracheostomy tube in synchrony with the heartbeat.

question

What nursing action will limit hypoxia when suctioning a client's airway?

answer

Apply suction only after catheter is inserted.

question

Which nursing action is important when suctioning the secretions of a client with a tracheostomy?

answer

Initiate suction as the catheter is being withdrawn.

question

You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to intervene?

answer

Removing the inner cannula and cleaning using standard precautions.

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