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Chapter 30: Care of Patients Requiring Oxygen Therapy or Tracheostomy

Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client with a new tracheostomy. Which assessment finding requires

the nurses immediate action?


Cuff pressure readings consistently between 14 and 20 mm Hg.
Need to change Velcro tube holders three times in 1 day.
Crackling sensation around the neck when skin is palpated.
Small amount of bleeding around the incision for the first few days.

a.
b.
c.
d.

ANS: C

Subcutaneous emphysema occurs when an opening or tear occurs in the trachea and air
escapes into fresh tissue planes of the neck. Air can also progress through the chest and other
tissues into the face. Inspect and palpate for air under the skin around the new tracheostomy. If
the skin is puffy and you can feel a crackling sensation, notify the physician immediately. Cuff
pressures should be maintained between 14 and 20 mm Hg or between 20 and 28 cm H2O.
Tracheostomy ties need to be changed at least once a day or whenever soiled. It is not
uncommon for a client with a new tracheostomy to have heavy secretions that would
necessitate changing them. It is not unusual to have a small amount of bleeding around the
incision for the first few days after surgical placement.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Analysis)
2. A client has a new tracheostomy and is receiving 60% oxygen via tracheostomy collar. Which

assessment finding requires immediate action by the nurse?


Constant, nonproductive coughing
Blood-tinged sputum
Rhonchi in upper lobes
Dry mucous membranes

a.
b.
c.
d.

ANS: A

Causes and manifestations of lung injury from oxygen toxicity include nonproductive cough,
substernal chest pain, GI upset, and dyspnea. Blood-tinged sputum is expected in clients with
new tracheostomies. Rhonchi in upper lobes indicates sputum that can be expectorated and is
not an emergent problem. Dry mucous membranes should be lubricated, and the clients
hydration status can be checked.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
3. A client has been placed on 6 L of humidified oxygen via nasal cannula. Which action by the

nurse is most appropriate?


a. Drain condensation back into the humidifier, maintaining a closed system.

b. Keep the water sterile by draining it from the water trap back into the humidifier.
c. Turn down the humidity when condensation begins to collect in the tubing.
d. Remove condensation in the tubing by disconnecting and emptying it appropriately.
ANS: D

Condensation often forms in the tubing when a client receives humidified high-flow oxygen.
Remove this condensation as it collects by disconnecting the tubing and emptying the water.
Some humidifiers and nebulizers have a water trap that hangs from the tubing so the
condensation can be drained without disconnecting. To prevent bacterial contamination, never
drain the fluid back into the humidifier or the nebulizer. Do not turn down the humidity
because the physician has ordered it and the client needs it. Minimize how long the tubing is
disconnected because the client does not receive oxygen during this period.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness
Management)
MSC: Integrated Process: Nursing Process (Implementation)
4. A client is being discharged with a tracheostomy and voices concern about his appearance.

What discharge teaching will assist the client with maintaining a positive body image?
Tell people how sick you were when they ask about the tracheostomy.
Your clothing can help hide the tracheostomy so it is not as noticeable.
You can put a bandage around your tracheostomy so no one will see it.
You have to ignore comments that people make about your appearance.

a.
b.
c.
d.

ANS: B

The client may have an alteration in body image because of the tracheostomy stoma.
Encourage the client to wear loose-fitting shirts and collars to help hide the appearance of the
stoma. Clients should not be encouraged to tell people about their illness, because they should
not be made to justify their appearance. You should not bandage the tracheostomy, because
airflow would be impaired. Ignoring comments will not help the clients self-image.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)
MSC: Integrated Process: Caring
5. A client is becoming frustrated because of an inability to communicate with a tracheostomy.

Which intervention by the nurse most effectively enhances communication?


Explain to the client that speech will be clear and distinct with a fenestrated tube.
Reassure the client that in time he or she will get used to the speech difficulties.
Place a sign above the clients bed indicating that the client cannot speak.
Provide the client with a communication board and call light within easy reach.

a.
b.
c.
d.

ANS: D

A communication board and the call light will reassure the client that needs will be
communicated and met. It is doubtful that the client with a tracheostomy will ever speak
clearly and distinctly, no matter what type of tube he or she uses. Reassuring the client that he
or she will get used to the speech difficulties does nothing to alleviate the discomfort and fear
associated with impaired communication. Placing a sign above the clients bed indicating that
he cannot speak will not enhance his ability to communicate, although it may help staff
remember that the client has impaired communication.
DIF: Cognitive Level: Application/Applying or higher

REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)


MSC: Integrated Process: Caring
6. A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds the client

cyanotic with labored respirations. Which action does the nurse perform first?
Remove bedding from around the adaptor opening.
Listen to lung sounds and obtain a respiratory rate.
Call respiratory therapy to check oxygen saturation.
Notify the provider or Rapid Response Team immediately.

a.
b.
c.
d.

ANS: A

The Venturi mask works by drawing in a specific amount of air to mix with the oxygen
through holes in an adaptor fitted at the bottom of the mask. Holes of different sizes allow
different amounts of room air to be entrained, changing the amount of oxygen delivered.
Bedding (or clothing) wrapped around those holes would effectively change the FiO2. The
nurse should ensure that the holes remain unobstructed. Other options are appropriate but are
not the first choice, because this simple step may be what solves the problem.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Safe Use of Equipment)
MSC: Integrated Process: Nursing Process (Implementation)
7. A client requires oxygen received via a face mask but wants to remain as mobile as possible

once discharged home. Which intervention by the home health nurse best provides the client
with maximal mobility?
a. Arrange a consultation with pulmonary rehabilitation to decrease oxygen needs.
b. Encourage the client to remove the mask occasionally to assess tolerance.
c. Add extra connecting pieces of tubing to the clients existing oxygen setup.
d. Change the face mask to a nasal cannula occasionally, such as at mealtimes.
ANS: C

To increase mobility, up to 50 feet of connecting tubing can be used with connecting pieces. A
client with a chronic respiratory condition needing home oxygen may not be able to decrease
oxygen needs through pulmonary rehabilitation, but that would not increase mobility with an
oxygen device. The nurse should not independently encourage the client to remove the mask
for periods of time or change to a cannula.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Planning)
8. A client has been brought in by the rescue squad to the emergency department. The client is

having an acute exacerbation of chronic obstructive pulmonary disease (COPD) and is


severely short of breath. On arrival, the client is on 15 L/min of oxygen via rebreather mask.
Which action by the nurse takes priority?
a. Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cannula.
b. Perform a thorough respiratory assessment and attach pulse oximetry.
c. Call the laboratory to obtain arterial blood gases as soon as possible.
d. Obtain a stat chest x-ray, then slowly wean the clients oxygen down.
ANS: B

Oxygen-induced hypoventilation can occur in clients with chronically elevated PCO2 levels,
such as those seen in COPD. Giving oxygen can eliminate their hypoxic drive to breathe and
can cause respiratory arrest. However, hypoxemia is a greater threat to an acutely ill client
than is the potential for oxygen-induced hypoventilation, and clients should be given the
amount of oxygen they require. The nurse should perform a thorough respiratory assessment
and should monitor the client for signs of this problem, rather than automatically reducing
oxygen delivery. Blood gases and a chest x-ray will also be obtained, but they do not take
priority over assessing and monitoring the client.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care
Establishing Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
9. The nurse is caring for a client with orders for oxygen at 5 L/min. Approximately how much

FiO2 is the client receiving?


a. 24%
b. 28%
c. 36%
d. 40%
ANS: D

A nasal cannula can provide oxygen at 0.5 to 6 L/min, corresponding to an FiO2 range of 25%
to 40%. At 5 L/min, the client is receiving 40% oxygen.
DIF: Cognitive Level: Knowledge/Remembering
REF: Table 30-1, p. 566
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness
Management)
MSC: Integrated Process: Nursing Process (Analysis)
10. A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory

problem is becoming increasingly confused. What does the nurse do first?


Notify the health care provider.
Assess the clients pulse oximetry.
Document the observation.
Raise the head of the bed.

a.
b.
c.
d.

ANS: B

Cerebral hypoxia is a cause of confusion and is a sensitive indicator that the client needs more
oxygen. Although you would want to notify the provider of the change in the clients
condition, the best action is first to assess pulse oximetry and then to increase the oxygen. You
would not just document the assessment finding without intervening. Raising the head of the
bed would not help the client oxygenate better.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness
Management)
MSC: Integrated Process: Nursing Process (Implementation)
11. The nurse assesses a client who is receiving oxygen via a partial rebreather mask. Which

assessment finding does the nurse intervene to correct?


a. The bag is two thirds inflated during inhalation.
b. The clients pulse oximetry reading is 93%.

c. The oxygen flow rate is 2 L/min.


d. The arterial oxygen level is 90%.
ANS: C

Flow rate should be 6 to 11 L/min. A flow rate of 2 L/min will not adequately inflate the bag.
A bag that is two thirds inflated is desired. A pulse oximetry reading of 93% and higher is
adequate, as is an arterial oxygenation of 90%.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
12. A client is to be discharged home on oxygen therapy. What information does the nurse teach

the client?
Carry the H cylinder tank on short trips.
Only use the E tank when stationary.
The D or C cylinder can be carried.
Roll the tank gently when transporting.

a.
b.
c.
d.

ANS: C

The D and C cylinders are small enough to be carried. The H cylinder cannot be carried. The
E tank can be transported. The tanks should not be rolled and should be carried only in a stand
or a rack.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 570
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
13. The nurse assesses a client with a new tracheotomy, and the tracheostomy tube is pulsating in

synchrony with the clients heartbeat. Which is the nurses priority action?
Notify the health care provider immediately.
Stabilize the tube by reapplying the ties.
Change the inner cannula of the tube.
Increase the inflation pressure of the cuff.

a.
b.
c.
d.

ANS: A

If a tracheostomy tube is pulsating with the clients heart rate, this could indicate proximity to
the innominate artery and may cause erosion of the artery if left in this position. The provider
should be notified immediately. Reapplying the ties, changing the inner cannula, and
increasing the inflation pressure of the cuff are all interventions that will not solve the
immediate problem of proximity of the tube to the innominate artery.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
14. A client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds

the client cyanotic, with the tracheostomy tube lying on his chest. Which action by the nurse
takes priority?
a. Auscultate breath sounds bilaterally.

b. Ventilate with a resuscitation bag and mask.


c. Call a code or the Rapid Response Team.
d. Insert a new obturator into the neck.
ANS: B

Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy
tract has not matured and replacement is difficult. First, ventilate the client using a manual
resuscitation bag and facemask while another nurse calls for help. Although auscultation of
breath sounds is important, the clients airway must be opened and ventilation started.
Ventilation should begin while another nurse calls the code. Reinsertion of a fresh
tracheostomy tube will require the physicians intervention.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical
Emergencies)
MSC: Integrated Process: Nursing Process (Implementation)
15. While suctioning a client who had a tracheostomy placed 4 days ago, the nurse notes particles

of food in the tracheal secretions. Which action by the nurse is most appropriate?
Increase the inflation pressure in the tracheostomy cuff.
Add blue dye to a beverage to assess for aspiration.
Make the client NPO and notify the health care provider.
Perform a more thorough assessment of the client.

a.
b.
c.
d.

ANS: D

Before calling the provider, the nurse needs more data, such as lung sounds, presence of
cough, pulse oximetry reading, and possibly mental status. The nurse could temporarily make
the client NPO while conducting this assessment, but calling the provider must wait until he
or she has more complete data. The nurse should not decide to increase the inflation pressure
in the tracheostomy cuff on his or her own. Adding dye to food, drink, or tube feeding
formulas was commonly done in the past but should be avoided because the dye is toxic to
lung tissues if aspirated.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
16. The nurse is teaching a client about his fenestrated tracheostomy tube. Which statement by the

client indicates an accurate understanding of the tube?


Im glad I will still be able to talk with this tube in place.
It is great that this tube does not have to be cleaned regularly.
This tube will not get dislodged because it never needs suctioning.
Because I cant swallow, I will need another tube for eating.

a.
b.
c.
d.

ANS: A

The client can speak with a fenestrated tube, which has a hole in it and allows air to flow over
the vocal cords. The tube still needs to be cleaned and suctioned. The tube may become
dislodged, and the client is able to swallow.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)
MSC: Integrated Process: Teaching/Learning

17. The nurse observes a nursing student suctioning a client. Which intervention by the student

nurse requires the supervising nurse to intervene?


Checking oxygen saturation post suctioning
Hyperoxygenating the client after removal of the catheter
Applying intermittent suction during catheter removal
Applying suction when the catheter is inserted

a.
b.
c.
d.

ANS: D

Applying suction as the catheter is introduced allows the tubing to adhere to the airway and
destroys cells. The other options are appropriate actions on the part of a nurse or student who
is suctioning a client.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
18. The nurse assesses a client during suctioning. Which finding indicates that the procedure

should be stopped?
Heart rate increases from 86 to 102 beats/min.
Respiratory rate increases from 16 to 20 breaths/min.
Blood pressure increases from 110/70 to 120/80 mm Hg.
Heart rate decreases from 78 to 40 beats/min.

a.
b.
c.
d.

ANS: D

A decrease in heart rate indicates that the client is not tolerating the procedure, and the
vasovagal reflex may be stimulated. An increase in heart rate may be stimulated by suctioning
and is expected, as is a slight increase in blood pressure. A slight increase in respiratory rate
after the procedure might be caused by the feeling of oxygen being suctioned from the clients
airway, along with secretions.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Analysis)
19. A client is being discharged home with a tracheostomy. Which action does the nurse teach the

client to decrease the risk for aspiration while eating?


Swallow quickly.
Thicken all liquids.
Rinse all food with water.
Chew food completely.

a.
b.
c.
d.

ANS: B

Thickening liquids may assist the client in swallowing and may help prevent aspiration.
Swallowing quickly will not decrease the risk of aspiration and may actually put the client at
greater risk. It is not recommended that the client drink water to wash down food. Chewing
food completely will help prevent choking but will not decrease aspiration risk.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning


20. The nursing student is performing tracheostomy care on a client. Which action by the student

leads the supervising nurse to intervene?


Using folded gauze dressings on both sides of the stoma
Cutting a slit in a gauze 4 4 pad to fit around the stoma
Applying new tracheostomy ties before removing old ones
Tying the twill tape in a square knot on the side of the neck

a.
b.
c.
d.

ANS: B

Tracheostomy dressings should be made from gauze pads with a manufactured slit in them
that fits around the tube. If none are available, use two gauze pads folded in half placed on
either side of the tube. Cutting a piece of gauze could result in entry of tiny shreds of the
gauze the tracheostomy. The other interventions are appropriate.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
21. A client receiving high-flow oxygen has new crackles and diminished breath sounds since the

last assessment 1 hour ago. Which action by the nurse is most appropriate?
Call respiratory therapy and request a bronchodilator treatment.
Instruct the client to use the spirometer and to cough and deep breathe.
Consult with the health care provider and request an order for diuretics.
Ensure that the ordered FiO2 is what is being provided.

a.
b.
c.
d.

ANS: B

A client who is receiving high rates of oxygen is at risk for absorption atelectasis, in which the
normal nitrogen in the air becomes diluted and the alveoli collapse. Hallmarks of this
condition include new onset of crackles and diminished breath sounds. Spirometer use,
coughing, and deep-breathing exercises would help to re-expand the alveoli. None of the other
options are appropriate choices.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Analysis)
22. Which statement by a client indicates an accurate understanding of home self-care of a

tracheostomy?
a. The stoma should be left uncovered during the day to dry.
b. I need to put normal saline in my airway twice daily.
c. While showering, I need to keep water out of my airway.
d. I dont need to use tracheostomy ties on a daily basis.
ANS: C

The client should put a shield over the tracheostomy to keep water from entering the airway.
The airway should remain covered during the day with cotton or foam. Saline should be put in
the airway 10 to 15 times daily. Tracheostomy ties should be used daily.
DIF: Cognitive Level: Application/Applying or higher

REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)


MSC: Integrated Process: Teaching/Learning
23. A client is being weaned from a tracheostomy tube and has tolerated capping of the tube for

24 hours. Which action by the nurse is most appropriate?


Collect all materials needed for suturing the stoma shut.
Place a dry dressing over the stoma and tape it securely.
Assess the client for air leaking around the tube.
Select a smaller tracheostomy tube to be inserted.

a.
b.
c.
d.

ANS: B

The tube will be able to be removed after the client has tolerated capping of it for 24 hours.
Therefore, a dry dressing will be able to be placed over the stoma. The stoma will not be
sutured. It will heal on its own with a small scar. Airflow should be adequate around the
capped tube. The physician will not likely insert the next smallest size tube but instead will
remove the existing tube.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness
Management)
MSC: Integrated Process: Nursing Process (Implementation)
24. The nurse is preparing to receive a postoperative client who just had a tracheostomy. Which

action by the nurse takes priority?


Obtain report from the postanesthesia care unit.
Place a second tracheostomy tube and obturator at the bedside.
Review orders for postoperative pain medications.
Order supplies for tracheostomy care for 24 hours.

a.
b.
c.
d.

ANS: B

The nurse must ensure that a second tracheostomy tube with obturator is available at the
bedside in case of accidental decannulation, because tube dislodgment in the first 72 hours is
an emergency. Obtaining report and understanding pain medication orders are important for
any postoperative client, but for the tracheostomy client, having the extra material on hand is
critical. Obtaining supplies for tracheostomy care is not as high a priority as the other three.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care
Establishing Priorities)
MSC:
Integrated Process: Nursing Process (Planning)
25. A family member has been taught to provide oral care to a client with a tracheostomy. Which

statement by the family member indicates an accurate understanding of the correct way to
provide mouth care?
a. I can use glycerin swabs.
b. Ill use water and a toothette.
c. I can use hydrogen peroxide.
d. It is okay to use mouthwash.
ANS: B

The best choice for mouth care is water and a toothette because these are the least irritating.
Glycerin swabs, hydrogen peroxide, and mouthwash all are too irritating to the mucous
membranes of the mouth.

DIF: Cognitive Level: Comprehension/Understanding


REF: p. 576
TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortPersonal Hygiene)
MSC: Integrated Process: Teaching/Learning
26. The nurse is teaching a family member how to suction the clients tracheostomy at home.

Which information does the nurse include in the teaching plan?


a. Always suction using sterile technique.
b. Suction the mouth first and then the airway.
c. Be prepared to recannulate the tube frequently.
d. Suctioning with clean technique is acceptable.
ANS: D

The family member can suction using clean technique because fewer organisms are present in
the home than in the hospital. Never suction the mouth first because airway pathogenic
organisms could be introduced into the airway. The family member should not be required to
recannulate the tube except in an emergency.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 578
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
MULTIPLE RESPONSE
1. Which interventions help to prevent aspiration during eating for a client with a tracheostomy?

(Select all that apply.)


Provide close supervision for the client during eating and drinking.
Add liquids to foods to make them thinner and easier to swallow.
Inflate the tracheostomy cuff tube to maximum pressure before starting.
Let the client indicate readiness for another bite when being fed.
Have the client tuck the chin down and forward while swallowing.
Instruct the client to dry swallow to clear food particles from the throat.
Place the client in a semi-Fowlers position for an hour after eating.

a.
b.
c.
d.
e.
f.
g.

ANS: A, D, E, F

The client with a tracheostomy will require close supervision, even if the client is feeding
himself or herself. Do not rush the client. Allow him or her to indicate when ready for another
bite. Teaching interventions should include instructing the client to tuck the chin down and
forward while swallowing to encourage food to move down smoothly. Dry swallowing helps
remove food residue. Food may actually become easier to aspirate if it is thinner in texture.
The nurse should not initiate adding air to inflate the cuff of a tracheostomy tube further
without a physicians order; if possible, the cuff should be deflated during eating. Placing the
client in a semi-Fowlers position after the meal will not prevent aspiration.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)