NCLEX RN Practice Question # 398


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  1. Description
  • A tracheostomy is an opening made surgically directly into the trachea to establish an airway; tracheostomy tube is inserted into the opening and the tube attaches to the mechanical ventilator or another type of oxygen delivery device.
  • The tracheostomy can be temporary or permanent.
  1. Interventions
  • Assess respirations and for bilateral breath sounds.
  • Monitor arterial blood gases and pulse oximetry.
  • Encourage coughing and deep breathing.
  • Maintain a semi-Fowler’s to high Fowler’s position.
  • Monitor for bleeding, difficulty with breathing, absence of breath sounds, and crepitus (subcutaneous emphysema), which are indications of hemorrhage or pneumothorax.
  • Provide respiratory treatments as prescribed.
  • Suction fluids as needed; hyperoxygenate the client before suctioning.
  • If the client is allowed to eat, sit the client up for meals and ensure that the cuff is inflated (if the tube is not capped) for meals and for 1 hour after meals to prevent aspiration.
  • Monitor cuff pressures as prescribed.
  • Assess the stoma and secretions for blood or purulent drainage.
  • Follow the physician’s prescriptions and agency policy for cleaning the tracheostomy
  • site and inner cannula (many inner cannulas are disposable); usually, half-strength hydrogen peroxide is used.
  • Administer humidified oxygen as prescribed, because the normal humidification
  • process is bypassed in a client with a tracheostomy.
  • Obtain assistance in changing tracheostomy ties; after placing the new ties, cut and remove
  • the old ties holding the tracheostomy in place (some securing devices are soft and made with Velcro to hold the tube in place).
  • Keep a resuscitation (Ambu) bag, obturator, clamps, and a spare tracheostomy tube of
  • the same size at the bedside.


  1. Complications of a tracheostomy


Tube Obstruction


Difficulty in breathing

Noisy respirations

Difficulty in inserting the suction catheter

Thick, dry secretions

Unexplained peak pressures if client is on a mechanical ventilator

Prevention and Interventions

Assist the client to cough and deep breathe.

Provide humidification and suctioning.

Clean the inner cannula regularly.

The physician repositions or replaces the tube if obstruction

occurs as a result of cuff prolapse over the end of the


Tube Dislodgment

Prevention and Interventions

Secure the tube in place. Minimize manipulation and traction

on the tube. Ensure that the client does not pull

on the tube. Ensure that a tracheostomy tube of the

same type and size is at the client’s bedside.

Be familiar with institutional policy regarding replacement of

a tracheostomy tube as a nursing procedure.

During the first 72 hours following surgical placement of

the tracheostomy, the nurse manually ventilates the

client by using a manual resuscitation (Ambu) bag

while another nurse calls the Rapid Response team for


After 72 hours following surgical placement of the


n Extend the client’s neck and open the tissues of the

stoma to secure the airway.

n Grasp the retention sutures (if they are present) to

spread the opening.

n Use a tracheal dilator (curved clamp) to hold the stoma


n Prepare to insert a tracheostomy tube; place the obturator

into the tracheostomy tube, replace the tube, and

remove the obturator.

n Maintain ventilation by resuscitation (Ambu) bag.

n Assess airflow and bilateral breath sounds.

n If unable to secure an airway, call the Rapid Response

team and the anesthesiologist.

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