Airway management post test 5 PDF

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The study material for post-test....

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1. 1.ID: 18668355842 Which of the following can be removed for cleaning, especially if the patient has copious or tenacious secretions? A. B.

C.

The outer cannula of the tracheostomy tube. The inner cannula of the tracheostomy tube. Correct The inner cannula may be removed and cleaned, or if disposable, discarded and replaced. The outer cannula should never be removed. Removal of the outer cannula would cause the tracheostomy tract to close, and in turn this would close the patient's airway. The obturator is a stylet used for initial insertion of the tracheostomy tube and is then removed to allow for airflow. The area under the flange, as well as the flange itself, is cleaned but not removed because it aids in securing the entire system to the patient’s neck. The obturator. Incorrect

D. The flange. Awarded 0.0 points out of 1.0 possible points. 2. 2.ID: 18668355844 Which of the following would be an appropriate nursing diagnosis for the patient who has a tracheostomy tube? A.

Risk of impaired skin integrity. Correct The nurse must be alert to the development of skin irritation below the tracheostomy flange and around the site of insertion. Impaired mobility, fluid volume deficit, and risk of fluid volume excess are not related to the presence of a tracheostomy tube. The nurse must be alert for defining characteristics of other nursing diagnoses, including impaired airway clearance, infection, pain, or altered skin integrity.

B.

Impaired mobility.

C.

Fluid volume deficit.

D. Risk of fluid volume excess. Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 18668355838 A patient may go home with a tracheostomy tube. Before discharge, the patient and the patient’s family should be taught all of the following routine tracheostomy tube care measures except: A.

Recognizing signs and symptoms of hypoxia and how to prevent hypoxia.

B.

How to suction the tracheostomy tube.

C.

How to remove the tracheostomy tube. Correct The patient and/or the patient’s family should not remove the tracheostomy tube as this may result in closure of the patient’s airway. Only the inner cannula should be removed for cleaning. The patient and the patient’s family should be

taught tracheostomy care, including suctioning, cleaning, replacing the ties, and recognizing the signs and symptoms of hypoxia and infection so they may take corrective action or seek additional medical care. D.

Expected drainage from the tracheostomy and when to notify the health care provider. Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 18668355840 The nurse is preparing to perform routine tracheostomy care. Which statements, if made by the nurse, indicate that further instruction is needed? (Select all that apply.) A. B. C. D. E.

"I will drop the inner cannula into a sterile basin of normal saline." "After I secure the ends of the tracheostomy ties, I should be able to fit one finger loosely or two fingers snugly under the ties." "I will double knot the ties behind the patient's neck." Correct "I should clean the tracheostomy stoma in a circular motion from the stoma site moving outward approximately 2 to 4 inches."

"After I clean the inner cannula and replace it, I may use the brush to clean around the stoma." Correct The inner cannula should be dropped into the sterile basin of normal saline for cleaning, or if disposable, the inner cannula would be discarded. The ties should be secured in a double square knot on the side of the neck. One finger of slack prevents the ties from being too tight and also prevents movement of the tracheostomy tube. The stoma site should be cleaned to remove secretions. Moving in an outward circle pulls mucus and other contaminants away from the stoma to the periphery. The tracheostomy brush is used to remove thick or dried secretions from the cannula. It would be too harsh and contaminated to use on the peristomal skin. Sterile 4- ✕ 4-inch gauze is used to clean around the stoma. Awarded 0.0 points out of 2.0 possible points....