Exam 2: Tracheostomy & Trach Care (NCLEX) Spring
2023 Questions and Answers
For client safety and quality care, which technique is best for the nurse to use when
suctioning the client with a tracheostomy tube?
A. Hyperoxygenate before and after suctioning
B. Repeat suctioning until the tube is clear
C. Apply suction during insertion of the tube
D. Suction for 30 seconds
A
The client should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to
prevent hypoxemia. After suctioning, the client should be hyperoxygenated for 1-5
minutes, or until the client's baseline heart rate and oxygen saturation are within normal
limits.`
The client with a new tracheostomy has a soiled dressing. What is the best nursing
intervention?
A. Cut sterile 4 x 4 gauze to fit around the tracheostomy tube
B. Reinforce the dressing with sterile 4 x 4 gauze
C. Replace the dressing with clean, folded 4 x 4 gauze
D. Replace the dressing with sterile, folded 4 x 4 gauze
D
An older adult client is being discharged home with a tracheostomy. Which nursing
action is an acceptable assignment for an experienced LPN/LVN?
A. Complete the referral form for a home health agency
B. Suction the tracheostomy using sterile technique
C. Teach the client and spouse about tracheostomy
D. Consult with the physician about using a fenestrated tube
B
Complex sterile procedures are within the education, scope, and practice of the
experienced LPN/LVN.
A client has just arrived in the PACU following a successful tracheostomy procedure.
Which nursing action must be taken first?
A. Suction as needed
B. Clean the tracheostomy inner cannula and stoma
C. Listen to lung sounds
D. Change the tracheostomy dressing as needed
C
Assessment is the first phase of the nursing process. All other actions and procedures
are driven by assessment findings. The first nursing action for a client following an
airway procedure is to assess the client's respiratory status; this requires auscultation of
the lungs.
,The client who is concerned about getting a tracheostomy says, "I will be ugly, with a
hole in my neck." What is the nurse's best response?
A. "But you know you need this to breathe, right?"
B. Do you have a pretty scarf or a large loose collar that you could place over it?"
C. "Your family and friends probably won't even care."
D. "It won't take you long to learn to manage."
B
Suggesting strategies to cover the tracheostomy recognizes client concerns and
explores options for dealing with the effects of the procedure.
The older adult client with degenerative arthritis is admitted for tracheostomy surgery.
What is the best communication method for this client during the postoperative period?
A. Computer keyboard
B. Magic slate
C. Picture board
D. Pen and paper
C
A picture board does not require very much dexterity for communication. Dexterity can
be limited to the extent the client finds comfortable.
Respirations of the sedated client with a new tracheostomy have become noisy, and the
ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the
best immediate action by the nurse?
A. Humidifying the oxygen source
B. Increasing oxygenation
C. Removing the inner cannula of the tracheostomy
D. Suctioning the client
D
Suctioning the client will likely result in clear lung sounds and lower peak pressure, and
the appearance of the sputum will indicate whether bleeding is a concern.
A client with a tracheostomy is at increased risk for aspiration. Which nursing
intervention(s) will reduce this risk? SELECT ALL THAT APPLY.
A. Encourage frequent sipping from a cup
B. Encourage water with meals
C. Inflate the tracheostomy cuff during meals
D. Maintain the client upright for 30 minutes after eating
E. Provide small, frequent meals
F. Teach the client to "tuck" the chin down in the forward position to swallow
DEF
At least 30 minutes is required for thinner liquids in the stomach to be thickened in
combination with stomach contents and/or removed from the stomach; this reduces the
chance of aspiration.
Eating requires significant time and energy. When the client becomes tired, he is more
likely to aspirate. Shorter and more frequent intervals of eating tire the client less and
, reduce the chance of aspiration.
Tucking the chin downward helps to open the upper esophageal sphincter.
A new graduate RN discovers that her client, who had a tracheostomy placed the
previous day, has completely dislodged both the obturator and the tracheostomy tube.
Which action should the nurse take first?
A. Auscultate the client's breath sounds while applying a nasal cannula
B. Direct someone to call the Rapid Response Team while using a resuscitation bag
and facemask
C. Apply a 100% non-rebreather mask while administering high-flow oxygen
D. Replace the obturator while inserting the tracheostomy tube
B
Because a fresh tracheostomy stoma will collapse, the client will lose his airway
patency, which will require the nurse to ventilate the client through the mouth and nose
while waiting for assistance to re-cannulate the client. Directing someone else to call the
Rapid Response Team allows the nurse to provide immediate care required by the
client.
The client is being discharged home with a tracheostomy. Which statement by the client
indicates the need for further teaching about tracheostomy care?
A. "I can only take baths, no showers."
B. "I can put normal saline in my tracheostomy to keep the secretions from getting
thick."
C. "I should put cotton or foam over the tracheostomy hole."
D. "I will have to learn to suction myself."
A
The client does not understand that he can shower with the use of a shower shield over
the tracheostomy tube to prevent water from entering the airway. Additional teaching is
necessary.
The nurse is preparing to suction a client via a tracheostomy tube. The nurse should
plan to limit the suctioning time to a maximum of which time period?
a. 5 seconds
b. 10 seconds
c. 30 seconds
d. 60 seconds
B
The newly hired nurse is caring for a client who had a tracheostomy four hours ago.
Which action by the nurse, if noted by the charge nurse, would cause the charge nurse
to intervene?
a) The newly hired nurse adjusts the bed to a comfortable working position.
b) The newly hired nurse delegates care of the tracheostomy to a licensed
practical/vocational nurse (LPN/LVN).
c) The newly hired nurse explains what she is doing and the reason to the client, even
2023 Questions and Answers
For client safety and quality care, which technique is best for the nurse to use when
suctioning the client with a tracheostomy tube?
A. Hyperoxygenate before and after suctioning
B. Repeat suctioning until the tube is clear
C. Apply suction during insertion of the tube
D. Suction for 30 seconds
A
The client should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to
prevent hypoxemia. After suctioning, the client should be hyperoxygenated for 1-5
minutes, or until the client's baseline heart rate and oxygen saturation are within normal
limits.`
The client with a new tracheostomy has a soiled dressing. What is the best nursing
intervention?
A. Cut sterile 4 x 4 gauze to fit around the tracheostomy tube
B. Reinforce the dressing with sterile 4 x 4 gauze
C. Replace the dressing with clean, folded 4 x 4 gauze
D. Replace the dressing with sterile, folded 4 x 4 gauze
D
An older adult client is being discharged home with a tracheostomy. Which nursing
action is an acceptable assignment for an experienced LPN/LVN?
A. Complete the referral form for a home health agency
B. Suction the tracheostomy using sterile technique
C. Teach the client and spouse about tracheostomy
D. Consult with the physician about using a fenestrated tube
B
Complex sterile procedures are within the education, scope, and practice of the
experienced LPN/LVN.
A client has just arrived in the PACU following a successful tracheostomy procedure.
Which nursing action must be taken first?
A. Suction as needed
B. Clean the tracheostomy inner cannula and stoma
C. Listen to lung sounds
D. Change the tracheostomy dressing as needed
C
Assessment is the first phase of the nursing process. All other actions and procedures
are driven by assessment findings. The first nursing action for a client following an
airway procedure is to assess the client's respiratory status; this requires auscultation of
the lungs.
,The client who is concerned about getting a tracheostomy says, "I will be ugly, with a
hole in my neck." What is the nurse's best response?
A. "But you know you need this to breathe, right?"
B. Do you have a pretty scarf or a large loose collar that you could place over it?"
C. "Your family and friends probably won't even care."
D. "It won't take you long to learn to manage."
B
Suggesting strategies to cover the tracheostomy recognizes client concerns and
explores options for dealing with the effects of the procedure.
The older adult client with degenerative arthritis is admitted for tracheostomy surgery.
What is the best communication method for this client during the postoperative period?
A. Computer keyboard
B. Magic slate
C. Picture board
D. Pen and paper
C
A picture board does not require very much dexterity for communication. Dexterity can
be limited to the extent the client finds comfortable.
Respirations of the sedated client with a new tracheostomy have become noisy, and the
ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the
best immediate action by the nurse?
A. Humidifying the oxygen source
B. Increasing oxygenation
C. Removing the inner cannula of the tracheostomy
D. Suctioning the client
D
Suctioning the client will likely result in clear lung sounds and lower peak pressure, and
the appearance of the sputum will indicate whether bleeding is a concern.
A client with a tracheostomy is at increased risk for aspiration. Which nursing
intervention(s) will reduce this risk? SELECT ALL THAT APPLY.
A. Encourage frequent sipping from a cup
B. Encourage water with meals
C. Inflate the tracheostomy cuff during meals
D. Maintain the client upright for 30 minutes after eating
E. Provide small, frequent meals
F. Teach the client to "tuck" the chin down in the forward position to swallow
DEF
At least 30 minutes is required for thinner liquids in the stomach to be thickened in
combination with stomach contents and/or removed from the stomach; this reduces the
chance of aspiration.
Eating requires significant time and energy. When the client becomes tired, he is more
likely to aspirate. Shorter and more frequent intervals of eating tire the client less and
, reduce the chance of aspiration.
Tucking the chin downward helps to open the upper esophageal sphincter.
A new graduate RN discovers that her client, who had a tracheostomy placed the
previous day, has completely dislodged both the obturator and the tracheostomy tube.
Which action should the nurse take first?
A. Auscultate the client's breath sounds while applying a nasal cannula
B. Direct someone to call the Rapid Response Team while using a resuscitation bag
and facemask
C. Apply a 100% non-rebreather mask while administering high-flow oxygen
D. Replace the obturator while inserting the tracheostomy tube
B
Because a fresh tracheostomy stoma will collapse, the client will lose his airway
patency, which will require the nurse to ventilate the client through the mouth and nose
while waiting for assistance to re-cannulate the client. Directing someone else to call the
Rapid Response Team allows the nurse to provide immediate care required by the
client.
The client is being discharged home with a tracheostomy. Which statement by the client
indicates the need for further teaching about tracheostomy care?
A. "I can only take baths, no showers."
B. "I can put normal saline in my tracheostomy to keep the secretions from getting
thick."
C. "I should put cotton or foam over the tracheostomy hole."
D. "I will have to learn to suction myself."
A
The client does not understand that he can shower with the use of a shower shield over
the tracheostomy tube to prevent water from entering the airway. Additional teaching is
necessary.
The nurse is preparing to suction a client via a tracheostomy tube. The nurse should
plan to limit the suctioning time to a maximum of which time period?
a. 5 seconds
b. 10 seconds
c. 30 seconds
d. 60 seconds
B
The newly hired nurse is caring for a client who had a tracheostomy four hours ago.
Which action by the nurse, if noted by the charge nurse, would cause the charge nurse
to intervene?
a) The newly hired nurse adjusts the bed to a comfortable working position.
b) The newly hired nurse delegates care of the tracheostomy to a licensed
practical/vocational nurse (LPN/LVN).
c) The newly hired nurse explains what she is doing and the reason to the client, even
