Question

The nurse is performing tracheostomy care. If the client coughs out the inner cannula, the nurse should: A. Call the doctor B. Replace the inner cannula with a new one C. Hold open the stoma with forceps D. Begin rescue breathing

Short answer

Answer: Replace the inner cannula with a new one.

Step-by-step solution

Understand the scenario

A client with a tracheostomy coughs out the inner cannula, and the nurse must decide on an appropriate action.

Analyze the options

A. Call the doctor - This is generally not necessary in this situation, as it is not an emergency. B. Replace the inner cannula with a new one - This may be the most appropriate action, as it maintains the client's airway and safety. C. Hold open the stoma with forceps - This is not the most appropriate action, as it may damage the client's airway. D. Begin rescue breathing - This is not necessary, as the client is able to cough, indicating that they are breathing.

Choose the correct answer

Based on the analysis of each option, the nurse should choose Option B: Replace the inner cannula with a new one, as it is the best course of action to maintain the client's airway and safety.

Key concepts

Nursing Interventions

Nursing interventions are crucial actions taken by nurses to achieve goals in a patient's care plan. For instance, when providing tracheostomy care, interventions often focus on maintaining a patent airway, preventing infection, and ensuring the patient's comfort.

One important intervention is to replace the inner cannula with a new one if it is coughed out, as the continuous secure airway is essential for the patient. This step also reduces the risk of infection from a potentially contaminated cannula. Nurses should always have a spare inner cannula available, know the appropriate size for the patient, and be proficient in changing it swiftly to avoid respiratory distress. The intervention also includes monitoring for any signs of obstruction, infection, and providing patient education on tracheostomy care.

Exercise Improvement Advice:

Emphasize the need for timely action and reassure students that with proper training and preparation, such nursing interventions become second nature, reducing the potential stress of emergency situations.

NCLEX-PN Exam

The National Council Licensure Examination for Practical Nurses (NCLEX-PN) is a standardized exam that must be passed to become a licensed practical nurse (LPN). It includes a range of questions aimed to assess a candidate's readiness to provide safe and effective nursing care at the entry level.

Questions on the exam, such as those related to tracheostomy care, test not only the nurse's factual knowledge but also their critical thinking and decision-making skills. For example, being presented with a scenario where a patient coughs out the inner cannula requires understanding of both the procedure and the urgency of each potential action. Candidates are expected to prioritize patient safety and apply evidence-based practices. The NCLEX-PN often utilizes multiple-choice questions to test these competencies, and so proper preparation for these scenarios is key.

Studying Tips:

Practice by reviewing scenarios commonly encountered in clinical settings and simulate the decision-making process. This will increase confidence and comfort with the material, which can be beneficial for the actual exam situation.

Respiratory Management

Respiratory management encompasses the various techniques and procedures used to support an individual's breathing. For patients with a tracheostomy, effective respiratory management is essential to maintain an open airway and prevent complications.

Regular monitoring and care of the tracheostomy are a part of respiratory management, ensuring the equipment is functioning correctly and any issues are addressed promptly. If a patient coughs out the inner cannula, the nurse must act quickly to replace it in order to maintain the integrity of the airway.

Prevention plays a large role in respiratory management as well. This includes educating patients and caregivers on proper tracheostomy care, recognizing signs of respiratory distress, and understanding when to seek medical attention. Furthermore, ongoing assessment is vital to identify early signs of complications such as infection, obstruction, or dislodgement of the tracheostomy tube.

Key Takeaway:

Respiratory management is a continual process that requires vigilance, competency in tracheostomy care, and readiness to intervene as needed. Nurses play a central role in ensuring that patients with tracheostomies receive comprehensive respiratory support.