Deck 27: Caring for the Client With a Tracheostomy

Question 1

Which task could the nurse safely delegate to the assistive personnel (AP)?

A) Capping a tracheostomy tube
B) Performing tracheostomy care
C) Increasing oxygen concentration delivered to the client
D) Providing routine client care

Answer 1

D
Explanation:1. Capping a tracheostomy tube involves the application of scientific knowledge, assessment skills, and problem solving, and therefore needs to be performed by a nurse or respiratory therapist.
2. Performing tracheostomy care involves the application of scientific knowledge, assessment skills, and problem solving, and therefore needs to be performed by a nurse or respiratory therapist.
3. Increasing oxygen concentration involves the application of scientific knowledge, assessment skills, and problem solving, and therefore needs to be performed by a nurse or respiratory therapist.
4. The AP could safely perform routine client care such as measuring vital signs, bathing the client, or emptying indwelling catheter collection bags.

Question 2

When preparing to cap the client's tracheostomy tube with a speaking valve, which nursing action should be omitted before placing the valve?

A) Suctioning the oropharynx if there are any secretions present
B) Asking the client to cough
C) Suctioning the tracheostomy tube
D) Deflating the cuffed tracheostomy tube

Answer 2

C
Explanation:1. The tracheostomy tube would only be suctioned if indicated; this would not be a routine step to perform at all times. The other steps would routinely be performed prior to capping the tube.
2. The tracheostomy tube would only be suctioned if indicated; this would not be a routine step to perform at all times. The other steps would routinely be performed prior to capping the tube.
3. The tracheostomy tube would only be suctioned if indicated; this would not be a routine step to perform at all times. The other steps would routinely be performed prior to capping the tube.
4. The tracheostomy tube would only be suctioned if indicated; this would not be a routine step to perform at all times. The other steps would routinely be performed prior to capping the tube.

Question 3

A client has a tracheostomy with a disposable inner cannula. Which should the nurse do when replacing this part of the tracheostomy tube?

A) Affix the obturator to the new inner cannula
B) Ensure there is a replacement of the same type of tube
C) Select an inner cannula from the stock supply in the care area
D) Chose a replacement that is 2 inches shorter than the outer cannula

Answer 3

B
Explanation:1. The obturator is used to insert the outer cannula and is then removed.
2. The different types of disposable tubes are not interchangeable.
3. The different types of disposable tubes are not interchangeable.
4. The inner cannula is not 2 inches shorter than the outer cannula.

Question 4

A client covers the tracheostomy tube with a finger when wanting to talk. Which action should the nurse take when this is observed?

A) Praise the client for creativity
B) Suggest the client cover the tube with a gauze pad instead
C) Instruct the client that this process can lead to an infection
D) Recommend the client wear a clean glove when covering the tube

Question 5

A client with a tracheostomy asks assistive personnel (AP) for help capping the tube with a speaking valve. Which action should the AP take?

A) Cap the tube
B) Ask another AP to cap the tube
C) Report the client's request to the nurse
D) Apply the cap after completing tracheostomy care

Question 6

The nurse is caring for a client with a tracheostomy tube. Which information should the nurse omit from documentation?

A) Quality of lung sounds
B) Status of inner cannula
C) Drainage from the stoma
D) Location of the tracheostomy tie knot