Providing Tracheostomy Care Answer Key

1. How can the nurse best minimize a patient's risk for infection during tracheostomy care? A. Adhere to sterile technique when appropriate. B. Frequently assess for signs of local or systemic infection. C. Monitor for indications that tracheostomy care is needed. D. Instruct nursing assistive personnel (NAP) to report any changes in color or odor of tracheal drainage. Rationale: Adherence to sterile technique is the most important factor in minimizing the patient's risk for infection during tracheostomy care. Proper assessment is important but will not reduce the patient's risk for infection during tracheostomy care. Monitoring the patient for indications that tracheostomy care is needed will not reduce the patient's risk for infection. Although the NAP would be instructed to report changes in tracheal drainage, such notification will not minimize the patient's risk for infection. 2. Which nursing action shows the most effective planning for emergenc y care of a patient with a tracheostomy? A. Having a spare oxygen mask at the patient's bedside B. Keeping an obturator and a tracheostomy tube at the patient's bedside C. Reviewing the agency's policy regarding tracheostomy care D. Instructing the family to call immediately if the patient has difficulty breathing Rationale: Keeping an obturator and a tracheostomy tube of the correct size at the patient's bedside is the best way to plan for an emergency involving a tracheostomy, such as tube dislodgement. Having a spare oxygen mask at the bedside does not constitute adequate emergency planning for a patient with a tracheostomy. Reviewing the agency's policy is important, but does not by itself constitute effective emergency planning for a patient with a tracheostomy. Instructing the family to call for help if the patient has difficulty breathing is appropriate, but does not by itself constitute effective emergency planning for a patient with a tracheostomy. 3. Which intervention reduces the risk for skin breakdown in a patient with a new tracheostomy? A. Cleaning the stoma with hydrogen peroxide and drying thoroughly B. Cleaning and assessing the skin around the stoma C. Assessing temperature and reporting skin breakdown immediately D. Allowing the patient to re-oxygenate after each tracheal suctioning Rationale: Frequently cleaning and assessing the skin in the tracheostomy area will reduce the patient's risk for skin breakdown. Hydrogen peroxide is not used to cleanse the stoma and could injure the patient's skin. Assessing for signs of infection and reporting skin breakdown will not reduce the patient's risk for injury. Re-oxygenating after suctioning will not reduce the patient's risk for skin breakdown. 4. Which action may be delegated to nursing assistive personnel (NAP) regarding the care of a patient with a tracheostomy? A. Performing tracheostomy care for a patient whose tracheostomy was placed 1 week ago B. Removing the outer cannula and placing the obturator C. Holding the tracheostomy tube while the nurse changes the neck ties D. Monitoring oxygen saturation levels and placing oxygen if needed Rationale: NAP may hold the tube while the nurse changes the ties during tracheostomy care. If agency policy allows it, the NAP may perform tracheostomy care only for a patient with an established tracheostomy. Removing the outer cannula would mean that the entire tracheostomy would come out. Placing an obturator is not within the NAP's scope of practice. NAP may take a pulse oximetry reading but may not monitor changes or administer oxygen. 5. Which technique would the nurse use to change a patient's tracheostomy ties? A. Use a slipknot. B. Ensure that two fingers fit snugly under the tie. C. Knot the ends of the tie in the eyelets on the faceplate. D. Ask the patient to hold his or her breath while the ties are changed. Rationale: When the tie is secure, two fingers should fit snugly under it. A slipknot could become untied. Use a square knot on tracheostomy ties. The ends of the ties are not knotted at the eyelets on the faceplate. Doing so would make it difficult to change the ties when they become soiled. The patient is not asked to hold his or her breath during tracheostomy care.