Nclexrn Quiz: Tracheostomy Care And Suctioning Safety
20 questions · exam conditions
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Tracheostomy Care And Suctioning SafetyQuestion 1 of 20

A 5-year-old child with a tracheostomy for 2 months is on a pediatric unit. The provider writes orders for airway management. The child has SpO2 92% on humidified oxygen, RR 30/min, HR 118/min, BP 96/58 mm Hg, T 98.9°F, with thick secretions. The nurse should QUESTION which tracheostomy care order?

Use the lowest suction pressure that effectively removes secretions
Limit each suction pass to 5 seconds for this child
Use a catheter size appropriate for the tracheostomy to avoid occluding the airway
Instill 10 mL sterile normal saline into the tracheostomy before every suction pass
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Nclexrn Quiz: Tracheostomy Care And Suctioning Safety

Practice Tracheostomy Care And Suctioning Safety in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

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This quiz focuses on Tracheostomy Care And Suctioning Safety, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

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Question 1

A 5-year-old child with a tracheostomy for 2 months is on a pediatric unit. The provider writes orders for airway management. The child has SpO2 92% on humidified oxygen, RR 30/min, HR 118/min, BP 96/58 mm Hg, T 98.9°F, with thick secretions. The nurse should QUESTION which tracheostomy care order?

  1. Use the lowest suction pressure that effectively removes secretions
  2. Limit each suction pass to 5 seconds for this child
  3. Use a catheter size appropriate for the tracheostomy to avoid occluding the airway
  4. Instill 10 mL sterile normal saline into the tracheostomy before every suction pass (correct answer)
Explanation: This question tests clinical judgment in tracheostomy care, scrutinizing orders for pediatric appropriateness. The priority is maintaining airway patency and preventing complications such as fluid overload or infection from improper interventions. The nurse should question instilling 10 mL sterile normal saline into the tracheostomy before every suction pass, as this volume is excessive for a child and routine instillation is not advised. Lowest pressure, short passes, and appropriate catheter size are safe practices. The clinical reasoning involves considering pediatric physiology and thick secretions, avoiding unnecessary risks. Questioning ensures tailored care. A transferable nursing principle is that airway management in children must adapt adult protocols to prevent harm and ensure safety.

Question 2

A 60-year-old client with a tracheostomy placed 3 days ago is on a surgical floor. The nurse prepares to perform tracheostomy care; the client has SpO2 95% on 28% FiO2, RR 16/min, HR 84/min, BP 122/70 mm Hg, T 98.4°F. What is the nurse's PRIORITY action when performing tracheostomy care?

  1. Place the client supine with the neck extended to improve access to the stoma
  2. Maintain sterile technique for cleaning the inner cannula and stoma (correct answer)
  3. Delegate stoma cleaning to the unlicensed assistive personnel while the RN changes ties
  4. Apply a thick layer of lotion around the stoma to prevent skin breakdown
Explanation: This question tests clinical judgment in tracheostomy care, ensuring infection prevention during routine maintenance. The priority is maintaining airway patency and preventing complications such as infection from contaminated care. Maintaining sterile technique for cleaning the inner cannula and stoma is the best choice for ensuring client safety, as it reduces microbial introduction in a recent tracheostomy. Supine positioning increases aspiration risk; delegation to UAP is inappropriate for sterile tasks; thick lotion may harbor bacteria. The clinical reasoning involves assessing stable status but recognizing infection vulnerability post-procedure. Sterility protects the airway. A transferable nursing principle is that airway management incorporates aseptic techniques to prevent nosocomial infections and promote safety.

Question 3

A 65-year-old client with a long-term tracheostomy (uncuffed, 18 months) is admitted for dehydration. On assessment the nurse hears gurgling and notes copious secretions; SpO2 86% on 3 L/min humidified oxygen via trach mask, RR 30/min, HR 114/min, BP 110/68 mm Hg, T 98.1°F. Which action should the nurse take FIRST when suctioning a tracheostomy?

  1. Increase humidification and reassess in 30 minutes before suctioning
  2. Preoxygenate, then suction using intermittent suction while withdrawing the catheter (correct answer)
  3. Change the inner cannula and then suction only if SpO2 remains low
  4. Obtain a provider order for suctioning because the client is not ventilated
Explanation: This question tests clinical judgment in tracheostomy care, addressing gurgling in a long-term client with dehydration. The priority is maintaining airway patency and preventing complications such as hypoxia from accumulated secretions. Preoxygenating, then suctioning using intermittent suction while withdrawing the catheter is the best choice for ensuring client safety, as it clears the airway effectively with minimal trauma. Increasing humidification may help but delays; changing cannula is not first; no order is needed for indicated suctioning. The clinical reasoning involves assessing low SpO2 and gurgling as immediate needs for correct technique. Intermittent suction protects mucosa. A transferable nursing principle is that airway management prioritizes evidence-based techniques for safe secretion removal.

Question 4

A 47-year-old client is 12 hours post-tracheostomy placement after facial trauma; a cuffed tube is in place. The nurse notes mild bleeding at the stoma, SpO2 93% on 40% FiO2, RR 20/min, HR 92/min, BP 124/76 mm Hg, T 98.2°F. Which assessment finding requires IMMEDIATE intervention in a client with a tracheostomy?

  1. Small amount of oozing blood at the stoma in the first 24 hours
  2. New onset of subcutaneous emphysema (crepitus) around the neck and upper chest (correct answer)
  3. Client reports throat discomfort when coughing
  4. Moderate amount of thin, clear secretions in the tracheostomy
Explanation: This question tests clinical judgment in tracheostomy care, identifying complications post-placement. The priority is maintaining airway patency and preventing complications such as pneumothorax from air leaks. New onset of subcutaneous emphysema around the neck and upper chest requires immediate intervention, as it may indicate tracheal injury or improper tube placement. Mild bleeding is expected early; throat discomfort is common; thin secretions are normal. The clinical reasoning involves assessing for crepitus as a sign of air escaping into tissues, necessitating urgent notification. Prompt action prevents progression. A transferable nursing principle is that airway management includes monitoring for structural complications to ensure timely intervention and client safety.

Question 5

A 59-year-old client has had a cuffed tracheostomy for 2 weeks and is on a medical unit. During routine suctioning, the nurse plans multiple passes. The client's SpO2 is 92% on 28% FiO2, RR 24/min, HR 98/min, BP 130/76 mm Hg, T 98.6°F. Which action should the nurse take FIRST when suctioning a tracheostomy?

  1. Limit each suction pass to no more than 10–15 seconds (correct answer)
  2. Apply sterile gloves after removing the inner cannula and cleaning it
  3. Auscultate lung sounds for 5 minutes to determine if suctioning is still needed
  4. Request a provider order for each suction pass to prevent mucosal trauma
Explanation: This question tests clinical judgment in tracheostomy care, planning for multiple suction passes safely. The priority is maintaining airway patency and preventing complications such as hypoxia from prolonged suctioning. Limiting each suction pass to no more than 10–15 seconds is the best choice for ensuring client safety, as it minimizes oxygen deprivation and vagal stimulation. Applying gloves is procedural but not first; auscultating for 5 minutes delays; requesting orders per pass is unnecessary. The clinical reasoning involves assessing stable vitals but planning to avoid cumulative hypoxia. Time limits support recovery between passes. A transferable nursing principle is that airway management procedures must incorporate time constraints to protect client safety and physiological stability.

Question 6

A 61-year-old client with an uncuffed tracheostomy for 1 year is admitted for acute bronchitis. The nurse hears loud gurgling at the tracheostomy, notes copious secretions, SpO2 87% on 35% FiO2 trach mask, RR 30/min, HR 110/min, BP 150/86 mm Hg, T 99.7°F. Which action should the nurse take FIRST when suctioning a tracheostomy?

  1. Assess lung sounds again after repositioning the client to high Fowler's
  2. Insert the catheter without suction, then apply intermittent suction while withdrawing (correct answer)
  3. Apply suction while inserting the catheter to quickly remove secretions
  4. Change the tracheostomy ties to prevent skin breakdown before suctioning
Explanation: This question tests clinical judgment in tracheostomy care, focusing on proper suctioning technique for airway clearance. The priority is maintaining airway patency and preventing complications such as mucosal trauma or hypoxia from incorrect methods. Inserting the catheter without suction, then applying intermittent suction while withdrawing is the best choice for ensuring client safety, as it minimizes tissue damage and allows effective secretion removal. Reassessing after positioning is helpful but not first; applying suction while inserting causes trauma; changing ties is unrelated to suctioning. The clinical reasoning involves identifying gurgling and low SpO2 as needing immediate correct technique application. Intermittent suction reduces risks. A transferable nursing principle is that airway management techniques must prioritize gentleness to prevent injury and promote safety.

Question 7

A 74-year-old client with a long-term tracheostomy (uncuffed, 2 years) is in a rehabilitation unit. The nurse finds the client lethargic with increased work of breathing, audible gurgling, SpO2 82% on 5 L/min humidified oxygen via trach mask, RR 34/min, HR 120/min, BP 164/92 mm Hg, T 98.9°F. Which action should the nurse take FIRST when suctioning a tracheostomy?

  1. Encourage the client to cough forcefully and drink fluids to mobilize secretions
  2. Hyperoxygenate and suction the tracheostomy using sterile technique (correct answer)
  3. Obtain an order for a mucolytic medication prior to suctioning
  4. Perform stoma care and change the dressing to reduce infection risk
Explanation: This question tests clinical judgment in tracheostomy care, responding to acute respiratory distress in a long-term tracheostomy client. The priority is maintaining airway patency and preventing complications such as severe hypoxia from gurgling and increased work of breathing. Hyperoxygenating and suctioning the tracheostomy using sterile technique is the best choice for ensuring client safety, as it clears secretions and improves oxygenation immediately. Encouraging cough may not suffice; obtaining mucolytics delays; stoma care is secondary. The clinical reasoning involves recognizing lethargy and low SpO2 as urgent, prompting direct airway intervention. Sterile technique reduces infection risk. A transferable nursing principle is that in airway management, immediate suctioning takes precedence over supportive measures in obstruction scenarios to ensure safety.

Question 8

A 70-year-old client with a tracheostomy placed 5 days ago is on a medical-surgical unit. Current assessment: moderate thick secretions, coarse rhonchi, SpO2 92% on 28% FiO2 trach collar, RR 22/min, HR 96/min, BP 140/82 mm Hg, T 98.9°F. The provider writes several orders. The nurse should QUESTION which tracheostomy care order?

  1. Change the tracheostomy dressing using sterile technique every shift and as needed
  2. Suction the tracheostomy as needed using sterile technique
  3. Instill 10 mL sterile normal saline into the tracheostomy before each suction pass (correct answer)
  4. Maintain humidification with a heated humidifier or humidified trach collar
Explanation: This question tests clinical judgment in tracheostomy care, evaluating orders for appropriateness in secretion management. The priority is maintaining airway patency and preventing complications such as infection or desaturation from improper techniques. The nurse should question instilling 10 mL sterile normal saline into the tracheostomy before each suction pass, as routine saline instillation is not recommended and may cause harm. Changing dressings and suctioning as needed are standard; maintaining humidification prevents thick secretions. The clinical reasoning involves assessing moderate secretions and recognizing that saline can introduce bacteria or cause coughing. Questioning promotes evidence-based care. A transferable nursing principle is that airway management involves challenging orders that contradict best practices to ensure client safety.

Question 9

A 3-year-old child with a tracheostomy for 1 year is admitted for increased secretions. The child is crying and tachypneic; breath sounds are coarse with decreased air movement through the tracheostomy, SpO2 86% on humidified oxygen, RR 40/min, HR 150/min, BP 92/56 mm Hg, T 99.3°F. Which assessment finding requires IMMEDIATE intervention in a client with a tracheostomy?

  1. Crying and agitation during nursing care
  2. Mild redness under the tracheostomy ties
  3. Thin, clear secretions noted at the tracheostomy opening
  4. Decreased air movement through the tracheostomy with SpO2 86% (correct answer)
Explanation: This question tests clinical judgment in tracheostomy care, identifying urgent issues in a pediatric client with increased secretions. The priority is maintaining airway patency and preventing complications such as respiratory failure from decreased air movement. Decreased air movement through the tracheostomy with SpO2 86% requires immediate intervention, as it suggests obstruction needing suctioning. Crying is emotional; thin secretions are benign; mild redness is minor. The clinical reasoning involves assessing tachypnea and coarse sounds as critical in children, where airways are smaller. Swift action prevents decompensation. A transferable nursing principle is that airway management in pediatrics demands rapid response to subtle obstruction signs for safety.

Question 10

A 63-year-old client with a cuffed tracheostomy placed 1 week ago for prolonged ventilation suddenly becomes restless and cyanotic in the ICU. The nurse notes no airflow from the tracheostomy, high-pressure ventilator alarm, SpO2 76%, RR 10/min with shallow efforts, HR 132/min, BP 90/54 mm Hg. What is the nurse's PRIORITY action when performing tracheostomy care?

  1. Remove the inner cannula (if present) and attempt to suction the tracheostomy immediately. (correct answer)
  2. Deflate the cuff to allow air to pass around the tube while positioning the client upright.
  3. Obtain a stat chest x-ray to verify tracheostomy tube placement before adjusting the ventilator settings.
  4. Provide oral fluids to thin secretions once the client stabilizes and is able to swallow.
Explanation: The client's restlessness, cyanosis, no airflow, high-pressure alarm, and falling SpO2 signal acute tracheostomy obstruction. The airway must be reopened immediately: removing the inner cannula clears a plug that may be blocked there, and suctioning removes secretions from the tube lumen. Deflating the cuff does not remove an obstructing plug; it creates a small air leak around the tube and delays the definitive maneuver. Getting a chest x-ray first may eventually confirm tube position, but it is too slow during active hypoxia and does nothing to restore airflow. Giving oral fluids is not an airway intervention; it risks aspiration and is irrelevant to the immediate obstruction, even if the client later stabilizes. Therefore the priority is direct, immediate clearance via inner-cannula removal and suctioning.

Question 11

A 72-year-old client with a long-term cuffed tracheostomy is receiving tube feedings on a medical unit. The client has coarse rhonchi, SpO2 91% on 28% FiO2, RR 24/min, HR 98/min, BP 132/74 mm Hg, and copious secretions. Which action should the nurse take FIRST when suctioning a tracheostomy?

  1. Apply suction while inserting the catheter to reduce procedure time and limit the client's discomfort
  2. Set suction pressure to the highest setting to remove thick secretions quickly before oxygen saturation drops
  3. Perform hand hygiene, apply sterile gloves, and maintain sterile technique for the suction catheter (correct answer)
  4. Obtain a sputum culture before suctioning to avoid contaminating the specimen and guide antibiotic selection
Explanation: Performing hand hygiene, applying sterile gloves, and maintaining sterile technique for the suction catheter is the correct first action. Tracheostomy suctioning is a sterile procedure because it bypasses normal upper-airway defenses; strict sterile technique prevents introducing organisms into the lower respiratory tract, especially in a tube-fed client at risk for aspiration. Applying suction while inserting the catheter is unsafe: suction should be intermittent and applied while withdrawing, because inserting under suction traumatizes mucosa and can worsen hypoxemia. Setting pressure to the highest setting is also unsafe; high negative pressure damages tracheal tissue and can drop oxygen saturation. Obtaining a sputum culture before suctioning delays the urgent airway clearance this client needs; a culture may be indicated later, but it is not part of the immediate suctioning procedure. Therefore, the first action is to establish the sterile field and use sterile technique for the catheter.

Question 12

A 56-year-old client is 12 hours post–total laryngectomy with a new cuffed tracheostomy placed in the OR. The client has audible gurgling at the trach, coarse crackles, SpO2 88% on humidified trach collar at 40% FiO2, RR 28/min, HR 112/min, BP 146/84 mm Hg, T 99.1°F. Which action should the nurse take FIRST when suctioning the tracheostomy?

  1. Instill 3–5 mL of sterile normal saline into the tracheostomy to loosen secretions
  2. Hyperoxygenate the client, then insert the catheter without suction until resistance is met (correct answer)
  3. Remove the inner cannula and soak it in hydrogen peroxide before suctioning
  4. Auscultate lung sounds and document sputum characteristics before suctioning
Explanation: This question tests clinical judgment in tracheostomy care, specifically the proper suctioning technique for a new postoperative tracheostomy. The priority is maintaining airway patency and preventing complications such as hypoxia or trauma during suctioning. Hyperoxygenating the client before suctioning and inserting the catheter without suction until resistance is met (option B) is the best choice for ensuring client safety, as it prevents hypoxia during the procedure and minimizes tracheal trauma. Instilling saline (option A) is no longer recommended as it can cause hypoxia and increase infection risk; removing the inner cannula before suctioning (option C) would compromise the airway and is contraindicated; while auscultating lung sounds (option D) is important for assessment, it does not address the immediate need for airway clearance in a client with signs of respiratory distress. The clinical reasoning focuses on evidence-based suctioning techniques that prioritize oxygenation and minimize complications. When a client shows signs of airway obstruction (gurgling, low SpO2, tachypnea), the nurse must act quickly to clear secretions while maintaining adequate oxygenation throughout the procedure. The transferable nursing principle is that airway management always requires balancing the need for secretion removal with the prevention of hypoxia and tissue trauma.

Question 13

A 60-year-old client is 24 hours post-op with a new cuffed tracheostomy and has thick secretions requiring suctioning. Current status: SpO2 93% on 35% FiO2 via trach collar, RR 22/min, HR 96/min, BP 128/70 mm Hg, T 98.4°F. The nurse should QUESTION which tracheostomy care order?

  1. Use sterile technique to clean the inner cannula per facility protocol
  2. Change tracheostomy ties with a second trained staff member present
  3. Instill 5–10 mL sterile normal saline routinely before each suction pass (correct answer)
  4. Provide humidified oxygen to help mobilize secretions
Explanation: This question tests clinical judgment in tracheostomy care by identifying unsafe practices that should be questioned. The priority is maintaining airway patency and preventing complications such as infection, hypoxia, or increased intracranial pressure from routine saline instillation. Instilling 5-10 mL sterile normal saline routinely before each suction pass (option C) should be questioned as this practice is no longer recommended and can cause hypoxia, increase infection risk, and stimulate excessive coughing. Using sterile technique for inner cannula cleaning (option A) is appropriate and follows best practices; changing ties with assistance (option B) prevents accidental decannulation and is correct; providing humidified oxygen (option D) helps mobilize secretions naturally and is evidence-based. The clinical reasoning recognizes that routine saline instillation has been shown through research to be harmful rather than helpful, causing oxygen desaturation, increasing bacterial colonization, and providing no benefit for secretion removal. Current evidence supports adequate humidification and hydration as safer methods for managing thick secretions. The transferable nursing principle is that nurses must question orders that contradict current evidence-based practice, particularly when those practices can cause patient harm.

Question 14

A 68-year-old client with COPD has had an uncuffed tracheostomy for 2 years and is admitted to a medical-surgical unit for pneumonia. Assessment shows thick yellow secretions, coarse rhonchi, SpO2 90% on 2 L/min via trach collar, RR 26/min, HR 104/min, BP 138/78 mm Hg, T 100.6°F; WBC 14,800/mm3 (normal 4,500–11,000). What is the nurse's PRIORITY action when performing tracheostomy care?

  1. Clean the stoma and apply a sterile split gauze dressing using aseptic technique
  2. Suction the tracheostomy to clear secretions and improve oxygenation (correct answer)
  3. Change the tracheostomy ties by removing the old ties first for easier access
  4. Deflate the cuff to reduce tracheal pressure before starting care
Explanation: This question tests clinical judgment in tracheostomy care for a client with a long-term uncuffed tracheostomy presenting with signs of respiratory infection. The priority is maintaining airway patency and preventing complications from retained secretions that could worsen the pneumonia. Suctioning the tracheostomy to clear secretions and improve oxygenation (option B) is the best choice for ensuring client safety, as the client shows clear signs of airway obstruction with thick secretions, hypoxia, and tachypnea. Cleaning the stoma (option A) is important for routine care but does not address the immediate respiratory compromise; changing ties by removing old ones first (option C) is unsafe and could lead to accidental decannulation; deflating the cuff (option D) is not applicable as this is an uncuffed tracheostomy. The clinical reasoning prioritizes immediate airway clearance when assessment findings indicate respiratory distress from secretion accumulation. With pneumonia, secretions become thicker and more copious, requiring prompt removal to maintain adequate gas exchange and prevent further respiratory deterioration. The transferable nursing principle is that airway patency takes precedence over all other aspects of tracheostomy care when signs of obstruction are present.

Question 15

A 50-year-old client with a tracheostomy for 10 days is on an acute care unit. The client is restless with coarse breath sounds, visible secretions at the trach, and SpO2 89% on 40% FiO2; RR 26/min, HR 110/min, BP 144/82 mm Hg, T 99.0°F. Which action should the nurse take FIRST when suctioning a tracheostomy?

  1. Suction for 20–30 seconds to fully clear secretions in one pass
  2. Advance the catheter while applying intermittent suction to minimize trauma
  3. Hyperoxygenate, then suction while withdrawing the catheter for no more than 10–15 seconds (correct answer)
  4. Administer an opioid analgesic before suctioning to prevent coughing
Explanation: This question tests clinical judgment in tracheostomy care, specifically the proper suctioning technique to minimize complications. The priority is maintaining airway patency and preventing complications such as hypoxia and vagal stimulation during suctioning. Hyperoxygenating, then suctioning while withdrawing the catheter for no more than 10-15 seconds (option C) is the best choice for ensuring client safety, as this technique prevents hypoxia and minimizes vagal stimulation that could cause bradycardia. Suctioning for 20-30 seconds (option A) is too long and will cause severe hypoxia; advancing with intermittent suction (option B) causes unnecessary trauma; administering opioids before suctioning (option D) could suppress respiratory drive and is contraindicated. The clinical reasoning emphasizes that suctioning removes not only secretions but also oxygen from the airways, making time limits and pre-oxygenation critical for safety. The 10-15 second limit is based on how long most people can tolerate breath-holding without significant hypoxia, and withdrawal suctioning minimizes tracheal trauma. The transferable nursing principle is that tracheostomy suctioning must balance effective secretion removal with prevention of hypoxia and vagal stimulation through proper technique and timing.

Question 16

A 6-year-old child with a tracheostomy placed 3 months ago for subglottic stenosis is brought to the pediatric unit for observation. The caregiver reports increased secretions and the child is coughing but cannot clear mucus; breath sounds are coarse, SpO2 89% on room air, RR 34/min, HR 126/min, BP 98/60 mm Hg, T 98.4°F. Which action should the nurse take FIRST when suctioning a tracheostomy?

  1. Administer an as-needed bronchodilator nebulizer treatment before suctioning
  2. Apply suction continuously for 20–30 seconds to remove thick secretions
  3. Insert the catheter while applying suction to reduce coughing
  4. Use a suction catheter with an external diameter no more than half the internal diameter of the tracheostomy tube (correct answer)
Explanation: This question tests clinical judgment in tracheostomy care, focusing on safe suctioning techniques in a pediatric client with increased secretions. The priority is maintaining airway patency and preventing complications such as hypoxia or trauma during suctioning in a child with subglottic stenosis. Using a suction catheter with an external diameter no more than half the internal diameter of the tracheostomy tube is the best choice for ensuring client safety, as it prevents complete occlusion and allows air passage. Continuous suction for 20–30 seconds risks hypoxia; inserting with suction increases trauma; administering a bronchodilator may help but is not the first action. The clinical reasoning involves assessing coughing and low SpO2, selecting equipment to minimize risks in pediatrics. Proper sizing supports effective clearance without harm. A transferable nursing principle is that airway management in children requires equipment scaled to size to ensure safety and prevent iatrogenic injury.

Question 17

A 66-year-old client with a cuffed tracheostomy placed 4 days ago is receiving enteral feedings and is intermittently coughing. Current assessment: coarse rhonchi, SpO2 91% on 30% FiO2, RR 26/min, HR 102/min, BP 138/80 mm Hg, T 99.0°F. What is the nurse's PRIORITY action when performing tracheostomy care?

  1. Document the procedure and the character of secretions after completing the tracheostomy care and client assessment
  2. Clean the stoma with sterile cotton-tipped applicators from the stoma outward using normal saline solution
  3. Remove the soiled dressing and apply a new pre-cut gauze dressing around the stoma site
  4. Verify suction equipment is functional and set suction pressure to the appropriate range before starting (correct answer)
Explanation: The priority is to prepare for the possibility of suctioning. This client is coughing and has coarse rhonchi with SpO2 91%, so airway clearance is the immediate concern. Before beginning tracheostomy care, the nurse must ensure suction equipment works and the pressure is set within the safe range; this prevents delay and reduces the risk of hypoxemia or mucosal injury if suction becomes needed. Documenting the procedure and the character of secretions after completing the tracheostomy care and client assessment is important but occurs later and does not address the current respiratory risk. Cleaning the stoma with sterile cotton-tipped applicators from the stoma outward using normal saline solution is correct technique, but stoma hygiene is not the priority while the client shows signs of retained secretions. Removing the soiled dressing and applying a new pre-cut gauze dressing around the stoma site is a routine part of tracheostomy care, not the first action when respiratory distress is developing. In any situation where oxygenation or ventilation is threatened, the nurse prioritizes equipment readiness and interventions that maintain airway patency.

Question 18

A 55-year-old client is 2 days post-tracheostomy for airway protection after neck surgery; a cuffed tracheostomy tube has been in place for 48 hours. The client has thick secretions, rhonchi over the trachea, SpO2 90% on 30% FiO2 trach collar, RR 26/min, HR 104/min, BP 132/78 mm Hg, T 98.8°F. What is the nurse's PRIORITY action when performing tracheostomy care?

  1. Apply a clean, dry dressing under the tracheostomy flange after completing care
  2. Remove old tracheostomy ties and replace them with clean ties
  3. Suction the tracheostomy as needed to clear the airway before cleaning the stoma (correct answer)
  4. Clean the inner cannula with half-strength hydrogen peroxide and rinse with sterile saline
Explanation: This question tests clinical judgment in tracheostomy care, emphasizing the sequence of actions to maintain a clear airway post-surgery. The priority is maintaining airway patency and preventing complications such as aspiration or infection from thick secretions in a client with a recent tracheostomy. Suctioning the tracheostomy as needed to clear the airway before cleaning the stoma is the best choice for ensuring client safety, as it removes secretions that could be pushed into the airway during care. Applying a dressing is important but follows airway clearance; removing old ties without securing new ones risks tube dislodgement; cleaning the inner cannula is necessary but not the priority over suctioning. The clinical reasoning involves assessing for thick secretions and rhonchi, indicating the need for immediate airway clearance before other care steps. This sequence prevents complications like pneumonia and ensures effective care. A transferable nursing principle is that in airway management, always secure a patent airway before performing supportive interventions to promote client safety.

Question 19

A 58-year-old client with a cuffed tracheostomy for 5 days is on a surgical floor. After suctioning, the nurse notes HR 52/min (baseline 78/min), SpO2 84%, RR 10/min, and the client becomes pale and diaphoretic. Which assessment finding requires IMMEDIATE intervention in a client with a tracheostomy?

  1. Heart rate 52/min with pallor and diaphoresis after suctioning (correct answer)
  2. Small amount of blood-tinged sputum after suctioning
  3. Client reports suctioning is uncomfortable and makes them cough
  4. Thin, clear secretions noted in the suction tubing
Explanation: This question tests clinical judgment in tracheostomy care by recognizing a serious complication of suctioning that requires immediate intervention. The priority is maintaining airway patency and preventing complications such as severe vagal response that could lead to cardiac arrest. Heart rate 52/min with pallor and diaphoresis after suctioning (option A) requires immediate intervention as it indicates severe vagal stimulation causing symptomatic bradycardia that could progress to asystole. Small amount of blood-tinged sputum (option B) is common with suctioning and not immediately dangerous; client discomfort and coughing (option C) are expected responses; thin, clear secretions (option D) are normal findings. The clinical reasoning recognizes that vagal stimulation during suctioning can cause profound bradycardia, and when accompanied by pallor and diaphoresis, indicates compromised cardiac output requiring immediate intervention such as stopping suctioning, administering oxygen, and potentially atropine. This represents a medical emergency as severe bradycardia can rapidly progress to cardiac arrest. The transferable nursing principle is that symptomatic bradycardia following tracheostomy suctioning represents a life-threatening vagal response requiring immediate cessation of the procedure and emergency intervention to prevent cardiac arrest.

Question 20

A 68-year-old client is 24 hours post-total laryngectomy with a cuffed tracheostomy tube placed yesterday. The nurse notes audible gurgling at the tracheostomy, coarse crackles bilaterally, SpO2 88% on humidified trach collar at 35% FiO2, RR 28/min, HR 112/min, BP 146/84 mm Hg, T 99.1°F; ABG: pH 7.33 (7.35–7.45), PaCO2 50 mm Hg (35–45), PaO2 62 mm Hg (80–100). Which action should the nurse take FIRST when suctioning a tracheostomy?

  1. Instill 5–10 mL of sterile normal saline into the tracheostomy to loosen secretions
  2. Obtain a sputum culture before suctioning to avoid contamination
  3. Advance the suction catheter until resistance is met and apply continuous suction while advancing
  4. Hyperoxygenate the client with 100% oxygen before inserting the suction catheter (correct answer)
Explanation: This question tests clinical judgment in tracheostomy care, focusing on the initial steps in suctioning to address respiratory distress. The priority is maintaining airway patency and preventing complications such as hypoxia and mucus plugging in a post-laryngectomy client with signs of secretion accumulation. Hyperoxygenating the client with 100% oxygen before inserting the suction catheter is the best choice for ensuring client safety, as it increases oxygen reserves and minimizes desaturation during the procedure. Instilling saline is not routinely recommended as it may cause infection or desaturation; advancing the catheter with continuous suction risks mucosal trauma and is incorrect technique; obtaining a sputum culture is not the first action and delays intervention. The clinical reasoning involves recognizing signs of airway obstruction like gurgling, crackles, and low SpO2, prompting immediate preparation for safe suctioning. Hyperoxygenation supports oxygenation during brief apnea caused by suctioning, reducing risks like arrhythmias. A transferable nursing principle is that airway management always prioritizes oxygenation and patency to ensure client safety in respiratory emergencies.