Ch 25 iggy medsurg 1
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Questions and Answers

What should the nurse do if a client with a tracheostomy tube in place has food particles noted during suctioning?

  • Administer oral suctioning
  • Increase the suction pressure
  • Measure and compare cuff pressures (correct)
  • Elevate the head of the client's bed
  • Why would a nurse need to palpate the skin of the upper chest of a client with subcutaneous emphysema?

  • To assess heart rate
  • To evaluate muscle strength
  • To detect air leaks around the tracheostomy (correct)
  • To monitor body temperature
  • What can air leaking into the tissues surrounding a tracheostomy lead to?

  • Tracheomalacia
  • Emphysema (correct)
  • Subcutaneous bleeding
  • Increased heart rate
  • If a client with a tracheostomy is unstable, what action should the nurse take?

    <p>Call the Rapid Response Team</p> Signup and view all the answers

    What could be a consequence of constant pressure from a tracheostomy tube cuff?

    <p>Tracheomalacia</p> Signup and view all the answers

    Why is it essential for the nurse to monitor cuff pressures in a client with a tracheostomy tube?

    <p>To monitor for tracheomalacia</p> Signup and view all the answers

    What is the most appropriate action for a student to take when tying a tracheostomy tie?

    <p>Tying the knot at the side of the client's neck</p> Signup and view all the answers

    Which action by a student when suctioning a tracheostomy demonstrates the need for more teaching?

    <p>Applying suction while inserting the catheter</p> Signup and view all the answers

    Which action is appropriate for cleansing a tracheostomy site?

    <p>Using half-strength peroxide for cleansing</p> Signup and view all the answers

    When should a nurse suction a client with a tracheostomy?

    <p>Suctioning should be performed only when secretions are present</p> Signup and view all the answers

    What is the purpose of preoxygenating a client prior to suctioning a tracheostomy?

    <p>To reduce the risk of the client experiencing respiratory distress during the suctioning procedure</p> Signup and view all the answers

    What is the recommended duration for suctioning a client's tracheostomy?

    <p>Suctioning should be performed for 10 to 15 seconds each time</p> Signup and view all the answers

    What is the priority action for the nurse when a client with a tracheostomy experiences a coughing spell during a meal?

    <p>Assess the client's lung sounds</p> Signup and view all the answers

    What should be considered by the nurse after assessing a client who experienced a coughing spell during a meal?

    <p>Consult with the registered dietitian regarding thickened liquids</p> Signup and view all the answers

    What should an unlicensed assistive personnel (UAP) have done immediately after a client with a tracheostomy experienced a coughing spell during a meal?

    <p>Reported the incident immediately</p> Signup and view all the answers

    What action should the nurse take if a UAP fails to report a client's coughing spell during a meal?

    <p>Educate the UAP on reporting procedures</p> Signup and view all the answers

    After addressing a client's immediate oxygenation needs post-coughing spell, what should be the nurse's next step?

    <p>Consult with other healthcare team members as needed</p> Signup and view all the answers

    What is a key aspect that a student nurse providing tracheostomy care should ensure when changing ties?

    <p>Securing the device properly during tie changes</p> Signup and view all the answers

    What action should the nurse take if the client with a tracheostomy begins to hemorrhage?

    <p>Notify the provider and apply pressure at the bleeding site</p> Signup and view all the answers

    What is the recommended nursing action if a client has a tracheainnominate artery fistula?

    <p>Prepare the client for surgery</p> Signup and view all the answers

    What is a crucial nursing intervention for a client with a new tracheostomy experiencing Impaired Self-Esteem?

    <p>Promote social activities like joining a book club outside the home</p> Signup and view all the answers

    Why does the nurse ask someone else to notify the provider when a client may have a tracheainnominate artery fistula?

    <p>To ensure accurate information is relayed to the provider</p> Signup and view all the answers

    Which finding would be most concerning in a client with a new tracheostomy?

    <p>Family members assisting with stoma care</p> Signup and view all the answers

    How should a nurse respond if a client with a new tracheostomy experiences skin irritation around the stoma?

    <p>Increase the frequency of stoma care</p> Signup and view all the answers

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