Exam 2: Tracheostomy & Trach Care
Quiz_________________?
A client has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar.
Which assessment finding requires immediate action by the nurse?
a. Constant, nonproductive coughing
b. Blood-tinged sputum
c. Rhonchi in upper lobes
d. Dry mucous membranes -
Answer✅
A
Causes and manifestations of lung injury from oxygen toxicity include nonproductive cough,
substernal chest pain, GI upset, and dyspnea. Blood-tinged sputum is expected in clients with
new tracheostomies. Rhonchi in upper lobes indicates sputum that can be expectorated and
is not an emergent problem. Dry mucous membranes should be lubricated, and the client's
hydration status can be checked.
Quiz_________________?
A client has just arrived in the PACU following a successful tracheostomy procedure. Which
nursing action must be taken first?
1
, A. Suction as needed
B. Clean the tracheostomy inner cannula and stoma
C. Listen to lung sounds
D. Change the tracheostomy dressing as needed -
Answer✅
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.
Quiz_________________?
A client is 24 hours postoperative after a tracheostomy has been performed. The nurse
finds the client cyanotic, with the tracheostomy tube lying on his chest. Which action by the
nurse takes priority?
a. Auscultate breath sounds bilaterally.
b. Ventilate with a resuscitation bag and mask.
c. Call a code or the Rapid Response Team.
d. Insert a new obturator into the neck. -
Answer✅
B
Tube dislodgment in the first 72 hours after surgery is an emergency because the
tracheostomy tract has not matured and replacement is difficult. First, ventilate the client
using a manual resuscitation bag and facemask while another nurse calls for help. Although
auscultation of breath sounds is important, the client's airway must be opened and
ventilation started. Ventilation should begin while another nurse calls the code. Reinsertion
of a fresh tracheostomy tube will require the physician's intervention.
Quiz_________________?
A client is becoming frustrated because of an inability to communicate with a tracheostomy.
Which intervention by the nurse most effectively enhances communication?
2
, a. Explain to the client that speech will be clear and distinct with a fenestrated tube.
b. Reassure the client that in time he or she will get used to the speech difficulties.
c. Place a sign above the client's bed indicating that the client cannot speak.
d. Provide the client with a communication board and call light within easy reach. -
Answer✅
D
A communication board and the call light will reassure the client that needs will be
communicated and met. It is doubtful that the client with a tracheostomy will ever speak
clearly and distinctly, no matter what type of tube he or she uses. Reassuring the client that
he or she will get used to the speech difficulties does nothing to alleviate the discomfort and
fear associated with impaired communication. Placing a sign above the client's bed indicating
that he cannot speak will not enhance his ability to communicate, although it may help staff
remember that the client has impaired communication.
Quiz_________________?
A client is being discharged home with a tracheostomy. Which action does the nurse teach
the client to decrease the risk for aspiration while eating?
a. Swallow quickly.
b. Thicken all liquids.
c. Rinse all food with water.
d. Chew food completely. -
Answer✅
B
Thickening liquids may assist the client in swallowing and may help prevent aspiration.
Swallowing quickly will not decrease the risk of aspiration and may actually put the client at
greater risk. It is not recommended that the client drink water to wash down food.
Chewing food completely will help prevent choking but will not decrease aspiration risk.
Quiz_________________?
A client is being weaned from a tracheostomy tube and has tolerated capping of the tube for
24 hours. Which action by the nurse is most appropriate?
3
, a. Collect all materials needed for suturing the stoma shut.
b. Place a dry dressing over the stoma and tape it securely.
c. Assess the client for air leaking around the tube.
d. Select a smaller tracheostomy tube to be inserted. -
Answer✅
B
The tube will be able to be removed after the client has tolerated capping of it for 24 hours.
Therefore, a dry dressing will be able to be placed over the stoma. The stoma will not be
sutured. It will heal on its own with a small scar. Airflow should be adequate around the
capped tube. The physician will not likely insert the next smallest size tube but instead will
remove the existing tube.
Quiz_________________?
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 -
Answer✅
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.
4
Quiz_________________?
A client has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar.
Which assessment finding requires immediate action by the nurse?
a. Constant, nonproductive coughing
b. Blood-tinged sputum
c. Rhonchi in upper lobes
d. Dry mucous membranes -
Answer✅
A
Causes and manifestations of lung injury from oxygen toxicity include nonproductive cough,
substernal chest pain, GI upset, and dyspnea. Blood-tinged sputum is expected in clients with
new tracheostomies. Rhonchi in upper lobes indicates sputum that can be expectorated and
is not an emergent problem. Dry mucous membranes should be lubricated, and the client's
hydration status can be checked.
Quiz_________________?
A client has just arrived in the PACU following a successful tracheostomy procedure. Which
nursing action must be taken first?
1
, A. Suction as needed
B. Clean the tracheostomy inner cannula and stoma
C. Listen to lung sounds
D. Change the tracheostomy dressing as needed -
Answer✅
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.
Quiz_________________?
A client is 24 hours postoperative after a tracheostomy has been performed. The nurse
finds the client cyanotic, with the tracheostomy tube lying on his chest. Which action by the
nurse takes priority?
a. Auscultate breath sounds bilaterally.
b. Ventilate with a resuscitation bag and mask.
c. Call a code or the Rapid Response Team.
d. Insert a new obturator into the neck. -
Answer✅
B
Tube dislodgment in the first 72 hours after surgery is an emergency because the
tracheostomy tract has not matured and replacement is difficult. First, ventilate the client
using a manual resuscitation bag and facemask while another nurse calls for help. Although
auscultation of breath sounds is important, the client's airway must be opened and
ventilation started. Ventilation should begin while another nurse calls the code. Reinsertion
of a fresh tracheostomy tube will require the physician's intervention.
Quiz_________________?
A client is becoming frustrated because of an inability to communicate with a tracheostomy.
Which intervention by the nurse most effectively enhances communication?
2
, a. Explain to the client that speech will be clear and distinct with a fenestrated tube.
b. Reassure the client that in time he or she will get used to the speech difficulties.
c. Place a sign above the client's bed indicating that the client cannot speak.
d. Provide the client with a communication board and call light within easy reach. -
Answer✅
D
A communication board and the call light will reassure the client that needs will be
communicated and met. It is doubtful that the client with a tracheostomy will ever speak
clearly and distinctly, no matter what type of tube he or she uses. Reassuring the client that
he or she will get used to the speech difficulties does nothing to alleviate the discomfort and
fear associated with impaired communication. Placing a sign above the client's bed indicating
that he cannot speak will not enhance his ability to communicate, although it may help staff
remember that the client has impaired communication.
Quiz_________________?
A client is being discharged home with a tracheostomy. Which action does the nurse teach
the client to decrease the risk for aspiration while eating?
a. Swallow quickly.
b. Thicken all liquids.
c. Rinse all food with water.
d. Chew food completely. -
Answer✅
B
Thickening liquids may assist the client in swallowing and may help prevent aspiration.
Swallowing quickly will not decrease the risk of aspiration and may actually put the client at
greater risk. It is not recommended that the client drink water to wash down food.
Chewing food completely will help prevent choking but will not decrease aspiration risk.
Quiz_________________?
A client is being weaned from a tracheostomy tube and has tolerated capping of the tube for
24 hours. Which action by the nurse is most appropriate?
3
, a. Collect all materials needed for suturing the stoma shut.
b. Place a dry dressing over the stoma and tape it securely.
c. Assess the client for air leaking around the tube.
d. Select a smaller tracheostomy tube to be inserted. -
Answer✅
B
The tube will be able to be removed after the client has tolerated capping of it for 24 hours.
Therefore, a dry dressing will be able to be placed over the stoma. The stoma will not be
sutured. It will heal on its own with a small scar. Airflow should be adequate around the
capped tube. The physician will not likely insert the next smallest size tube but instead will
remove the existing tube.
Quiz_________________?
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 -
Answer✅
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.
4
