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NCLEX-RN · Question #475

NCLEX-RN Question #475: Real Exam Question with Answer & Explanation

The correct answer is B. Avoiding manipulation of the tracheostomy including cuff deflation. (A) The tracheal cuff should not be deflated within the first 24 hours following surgery. (B) To minimize bleeding, any manipulation, including cuff deflation, should be avoided. (C) Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area

Question

A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:

Options

  • ADeflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
  • BAvoiding manipulation of the tracheostomy including cuff deflation
  • CReporting any signs of crepitus immediately to the physician
  • DChanging tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to

Explanation

(A) The tracheal cuff should not be deflated within the first 24 hours following surgery. (B) To minimize bleeding, any manipulation, including cuff deflation, should be avoided. (C) Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. (D) The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.

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