Tracheostomy And Airway Care - NCLEX Pn

What is the correct action if you note bubbling or crackling under the skin around the trach site?

Report subcutaneous emphysema to the provider promptly. Indicates potential tracheal perforation or air leak requiring immediate medical evaluation to prevent complications.
Which action is correct for routine tracheostomy stoma care to reduce infection risk?

Clean with sterile technique and keep the area dry with a sterile dressing. Removes debris and bacteria while protecting the site to promote healing and prevent infection.
Which complication is suggested by bright red bleeding from the tracheostomy site?

Hemorrhage (possible tracheo-innominate fistula). Suggests arterial erosion, a life-threatening emergency needing urgent intervention.
What is the correct guideline for tracheostomy ties: how should they fit?

Secure with space for one finger between tie and neck. Balances secure tube placement with prevention of skin breakdown or circulatory compromise.
What is the recommended maximum suction time per pass for tracheostomy suctioning?

No longer than $10$ to $15$ seconds per pass. Limits hypoxia and mucosal trauma by minimizing oxygen deprivation during the procedure.
What is the priority nursing action for sudden respiratory distress after a new tracheostomy?

Assess airway patency and suction the tracheostomy. Addresses potential mucus plugs or obstructions as the most immediate cause of acute distress in fresh tracheostomies.
Which finding indicates an overinflated tracheostomy cuff requiring intervention?

Tracheal pain or pressure injury signs with no air leak at low volume. Excess pressure causes mucosal damage despite effective sealing, necessitating deflation or adjustment.
What is the primary purpose of a tracheostomy?

To maintain a patent airway via a surgical opening in the trachea. Bypasses upper airway obstructions or facilitates long-term mechanical ventilation by creating a direct tracheal access point.
What is the correct response if a speaking valve is applied while the cuff remains inflated?

Remove the valve immediately to prevent airway obstruction. Inflated cuff blocks exhalation, causing pressure buildup and potential barotrauma.
What is the correct action if you cannot pass a suction catheter through a tracheostomy tube?

Remove and replace the inner cannula; reassess patency. Clearing potential blockages in the removable inner component restores patency without dislodging the outer tube.
Which assessment finding most strongly suggests tracheostomy tube obstruction?

Increased work of breathing with decreased airflow through the tube. Indicates partial or complete blockage impeding normal ventilation through the artificial airway.
Identify the correct suction technique: apply suction on insertion or on withdrawal?

Apply suction only on withdrawal. Prevents tracheal wall trauma and atelectasis that could occur from suction during insertion.
What is the main reason humidification is essential for tracheostomy patients?

To prevent thick secretions and mucus plugging. Compensates for bypassed upper airways, which normally warm and moisten air, to keep secretions thin.
Which action reduces hypoxemia risk during tracheostomy suctioning?

Preoxygenate before suctioning. Increases oxygen reserves to compensate for the temporary removal of air during suctioning.
Which tracheostomy tube component is removed for routine cleaning to maintain patency?

Inner cannula (if present). Allows easy removal of secretions and debris to prevent obstruction without replacing the entire tube.
Which position best reduces aspiration risk during oral intake for a stable tracheostomy patient?

High Fowler position ( $90^\circ$ ) with swallowing precautions as ordered. Upright positioning uses gravity to aid swallowing and minimize reflux into the airway.
What is the priority action for suspected tracheo-innominate fistula bleeding?

Hyperinflate cuff and apply direct pressure; call rapid response. Temporarily controls massive bleeding by compressing the artery while summoning emergency support.
What is the purpose of the obturator during tracheostomy tube insertion?

To guide safe insertion by providing a rounded leading edge. Reduces trauma to tracheal tissues by providing a smooth, blunt tip during tube placement.
Which condition must be met before using a one-way speaking valve (Passy-Muir type)?

Cuff must be fully deflated. Permits exhalation around the tube through the upper airway for valve function and speech.
What is the correct immediate action if a tracheostomy tube becomes dislodged in the first $72$ hours?

Call for help and ventilate with bag-mask; do not blindly reinsert. Immature tract risks false passage with blind reinsertion, so prioritize alternative ventilation and expert assistance.
Which equipment must be kept at the bedside for every tracheostomy patient?

Obturator and spare tubes (same size and one smaller), plus suction setup. Ensures immediate availability for emergencies like dislodgement or obstruction to maintain airway patency.
What is the correct method to verify cuff inflation is not excessive?

Maintain minimal occlusive volume/pressure to prevent leak. Ensures adequate seal for ventilation while minimizing tracheal ischemia and necrosis risks.
Which tracheostomy tube part prevents aspiration and allows positive-pressure ventilation?

Inflatable cuff. Seals the trachea to protect against aspiration of secretions and enables effective delivery of ventilated air under pressure.
Which nursing action best promotes secretion clearance in a stable tracheostomy patient?

Encourage coughing and provide adequate hydration and humidification. Facilitates natural expulsion of secretions and maintains thin mucus consistency to avoid plugs.
What is the correct action if a patient with a cuffed tracheostomy cannot speak?

Deflate cuff only if ordered/appropriate; consider speaking valve when eligible. Allows airflow over vocal cords for phonation while ensuring safety in eligible patients.

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