A client has a newly created tracheostomy for mechanical ...

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A client has a newly created tracheostomy for mechanical ventilation after a surgical procedure. What action should the nurse plan for this client?
 
  1. Deflate the cuff of the tracheostomy tube every 2 hours for 5 minutes.
  2. Remove the tracheostomy ties and replace them with an elastic bandage.
  3. Remove the tracheostomy inner cannula.
  4. Tape the tracheostomy obturator to the head of the bed.

Question 2

The client is receiving oxygen by nonrebreather mask, but the bag is not deflating on inspiration. What action should be taken by the nurse?
 
  1. Turn the client to the left side.
  2. Increase the percentage of oxygen being delivered.
  3. Check for an airtight seal between the client's face and the mask.
  4. Increase the liter flow of oxygen being delivered.

[swimkari]

Answer to Question 1

Correct Answer: 4
Rationale 1: The cuff should not be deflated if the client is being mechanically ventilated.
Rationale 2: The tracheostomy ties are only removed when they are soiled and need to be changed.
Rationale 3: The tracheostomy inner cannula is only removed for cleaning.
Rationale 4: The obturator should be taped to the head of the bed so that it will be readily available if the client tracheostomy tube should become dislodged.

Answer to Question 2

Correct Answer: 4
Rationale 1: There is no need to turn the client to either side.
Rationale 2: All oxygen is delivered at 100, so there is no method to increase the percentage of oxygen being delivered.
Rationale 3: The seal between the client's face and the mask should be snug, but will not be airtight.
Rationale 4: If the bag attached to the nonrebreather mask is not deflating on inspiration, the nurse should increase the liter flow of the oxygen being delivered.

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Gracias!

[alexanderhamilton]

Excellent