Gas Exchange and Oxygenation

A nurse is collecting data for a client who has a tracheostomy and requires routine care. Which finding should the nurse identify as an indication that the client needs suctioning?

• Clear breath sounds bilaterally

• Oxygen saturation 98% on room air

• Audible gurgling and visible secretions at the tracheostomy opening

• Respiratory rate of 16/min with unlabored breathing

Answer explanation

Visible secretions, coarse/gurgling breath sounds, ineffective cough, restlessness, and decreased oxygen saturation are common signs that suctioning is needed.

A nurse is reviewing the plan of care for a client with a tracheostomy. Which action should the nurse plan to include to reduce the risk of accidental tracheostomy dislodgement during care?

• Remove the old trach ties before applying the new ones

• Stabilize the tracheostomy tube while changing the ties
  

• Clean the stoma site before securing the trach tube

• Loosen the ties to prevent skin irritation

Answer explanation

The nurse should always stabilize the trach tube during care, especially when changing ties, to prevent accidental dislodgement.

A nurse is performing open-system suctioning for a client with a tracheostomy. For how long should the nurse apply suction during each suction pass?

• 5 seconds

• 10–15 seconds
  

• 20–25 seconds

• 30 seconds

Answer explanation

Suction should be applied for no longer than 10–15 seconds per pass to reduce the risk of hypoxia and mucosal trauma.

A nurse is assisting with tracheostomy care for a client. Which action should the nurse take when cleaning around the stoma site?

• Use clean technique to reduce client discomfort

• Use sterile cotton-tipped applicators and sterile solution

• Remove the tracheostomy tube to fully clean the area

• Apply gauze cut into a slit from a regular dressing pack

Answer explanation

Tracheostomy care requires sterile technique. The nurse should use sterile supplies and sterile solution per policy. A pre-cut sterile trach dressing should be used rather than cutting gauze, which can leave fibers behind.

A nurse is evaluating a client after open-system suctioning of a tracheostomy. Which finding indicates the procedure was effective?

• Breath sounds are clearer and oxygen saturation improved

• Thick secretions remain visible at the tracheostomy opening

• Heart rate increased from 88/min to 118/min

• Client reports pain at the stoma site

Answer explanation

Effective suctioning should improve airway clearance, resulting in clearer breath sounds, improved oxygen saturation, and easier breathing.

A nurse is reviewing discharge teaching with a client who has a new tracheostomy. Which statement by the client indicates understanding of home tracheostomy care?

• “I will use clean gloves when I suction my trach at home.”

• “I will change my trach ties only when they become loose enough to fall off.”

• “I should cut regular gauze if I do not have a trach dressing.”

• “I do not need suction equipment if I can cough.”

Answer explanation

In the home setting, clean technique is often used for trach suctioning/care unless otherwise prescribed. The client should keep supplies available, secure ties properly, and avoid cutting gauze due to lint/fiber risk.

A nurse is teaching new coworkers about tracheostomy care. Which statement should the nurse include?

• “The nurse should remove the inner cannula only if the client requests it.”

• “Emergency tracheostomy equipment should be kept at the bedside.”

• “Trach ties should be loose enough to fit 3–4 fingers underneath.”

• “Suction should be performed on a routine schedule every hour.”

Answer explanation

Emergency supplies (extra trach tube of same size and one size smaller, obturator, suction equipment, oxygen source) should always be at bedside in case of obstruction or accidental decannulation.

A nurse is caring for a client with a tracheostomy who suddenly becomes restless and confused. Oxygen saturation has dropped from 96% to 88%. Which complication should the nurse suspect first?

• Hypoxia

• Hypertension

• Hyperglycemia

• Fluid overload

Answer explanation

Restlessness, confusion, and decreasing oxygen saturation are early signs of hypoxia. The nurse should assess airway patency and suction if indicated.

A nurse is caring for a client with a tracheostomy who is receiving enteral feedings. Which intervention helps reduce the risk of aspiration?

• Place the client flat during feeding

• Suction after every feeding regardless of assessment

• Keep the head of bed elevated during and after feeding

• Encourage the client to drink fluids quickly

A nurse is caring for a client with a tracheostomy receiving oxygen. Which intervention is most important when administering oxygen through a tracheostomy?

• Deliver oxygen without humidification

• Provide humidified oxygen as prescribed

• Limit fluid intake to prevent secretions

• Use a nonrebreather mask over the nose and mouth

Answer explanation

Clients with tracheostomies bypass the upper airway, so humidification is important to prevent thick secretions and mucus plugs.