NSE221-Midterm MC Questions (Latest
Updates) Questions and
Answers {Grade A } 100% Correct (Verified
Answers)
The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy
tube. Which action by the nurse would best determine if the cuff has been properly
inflated?
a. Use a manometer to ensure cuff pressure is at an appropriate level
.b. Check the amount of cuff pressure ordered by the health care provider.
c. Suction the patient first with a fenestrated inner cannula to clear secretions.
,d. Insert the decannulation plug before the nonfenestrated inner cannula is removed. -
correct answer a. Use a manometer to ensure cuff pressure is at an appropriate level
-> Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20
mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never
insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the
nonfenestrated inner cannula is removed. Otherwise, the patient's airway is occluded.
A health care provider's order is not required to determine safe cuff pressure. A
nonfenestrated inner cannula must be used to suction a patient to prevent tracheal
damage occurring from the suction catheter passing through the fenestrated openings.
Following a laryngectomy a patient coughs violently during suctioning and dislodges
the tracheostomy tube. Which action should the nurse take first?
a. Cover stoma with sterile gauze and ventilate through stoma.
,b. Attempt to reinsert the tracheostomy tube with the obturator in place.
c. Assess the patient's oxygen saturation and notify the health care provider.d.
Ventilate the patient with a manual bag and face mask until the health care provider
arrives.
d. Ventilate the patient with a manual bag and face mask until the health care provider
arrives. - correct answer B
-> The first action should be to attempt to reinsert the tracheostomy tube to maintain
the patient's airway. Assessing the patient's oxygenation is an important action, but it
is not the most appropriate first action in this situation
.
, Covering the soma with a dressing and manually ventilating the patient may be an
appropriate action if the nurse is unable to reinsert the tracheostomy tube.
Ventilating with a facemask is not appropriate for a patient with a total laryngectomy
because there is a complete separation between the upper airway and the trachea.
Which complication is the result of constant pressure exerted by a tracheostomy cuff
causing tracheal dilation and erosion of cartilage?
A. Tracheomalacia
B. Tracheal stenosis
C. Tracheoesophageal fistula
Updates) Questions and
Answers {Grade A } 100% Correct (Verified
Answers)
The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy
tube. Which action by the nurse would best determine if the cuff has been properly
inflated?
a. Use a manometer to ensure cuff pressure is at an appropriate level
.b. Check the amount of cuff pressure ordered by the health care provider.
c. Suction the patient first with a fenestrated inner cannula to clear secretions.
,d. Insert the decannulation plug before the nonfenestrated inner cannula is removed. -
correct answer a. Use a manometer to ensure cuff pressure is at an appropriate level
-> Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20
mm Hg or lower will avoid compression of the tracheal wall and capillaries. Never
insert the decannulation plug in a tracheostomy tube until the cuff is deflated and the
nonfenestrated inner cannula is removed. Otherwise, the patient's airway is occluded.
A health care provider's order is not required to determine safe cuff pressure. A
nonfenestrated inner cannula must be used to suction a patient to prevent tracheal
damage occurring from the suction catheter passing through the fenestrated openings.
Following a laryngectomy a patient coughs violently during suctioning and dislodges
the tracheostomy tube. Which action should the nurse take first?
a. Cover stoma with sterile gauze and ventilate through stoma.
,b. Attempt to reinsert the tracheostomy tube with the obturator in place.
c. Assess the patient's oxygen saturation and notify the health care provider.d.
Ventilate the patient with a manual bag and face mask until the health care provider
arrives.
d. Ventilate the patient with a manual bag and face mask until the health care provider
arrives. - correct answer B
-> The first action should be to attempt to reinsert the tracheostomy tube to maintain
the patient's airway. Assessing the patient's oxygenation is an important action, but it
is not the most appropriate first action in this situation
.
, Covering the soma with a dressing and manually ventilating the patient may be an
appropriate action if the nurse is unable to reinsert the tracheostomy tube.
Ventilating with a facemask is not appropriate for a patient with a total laryngectomy
because there is a complete separation between the upper airway and the trachea.
Which complication is the result of constant pressure exerted by a tracheostomy cuff
causing tracheal dilation and erosion of cartilage?
A. Tracheomalacia
B. Tracheal stenosis
C. Tracheoesophageal fistula
