Exam 2 Questions and Answers Latest

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Tracheostomy & Trach Care (NCLEX) Exam 2 Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

A nurse is preparing to suction a client’s tracheostomy. What is the first action the nurse should take?

• Insert the suction catheter

✔✔ b. Hyperoxygenate the client

• Apply suction while inserting
• Remove the inner cannula

A tracheostomy tube becomes dislodged 48 hours after placement. What is the nurse's priority action?

• Reinsert a new trach immediately

✔✔ b. Call for help and manually ventilate with a bag-valve mask

• Apply a warm compress to the neck
• Administer IV fluids

When performing tracheostomy care, how often should the inner cannula be cleaned or replaced? 1 / 4

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✔✔ a. Every 8 to 12 hours or per protocol

• Once daily only
• Every other day
• Weekly

Which of the following findings indicates a possible tracheostomy obstruction?

• Frequent yawning
• Clear breath sounds

✔✔ c. High-pitched stridor or difficulty breathing

• Moist mucous membranes

What equipment should the nurse keep at the bedside of a client with a fresh tracheostomy?

• Extra pillows and a pulse oximeter

✔✔ b. Obturator, spare tracheostomy tube, and suction equipment

• Feeding syringe and dressing kit
• Ice pack and nasal cannula

Which action by the nurse maintains aseptic technique during tracheostomy care? 2 / 4

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• Using clean gloves for the entire procedure
• Changing the trach ties before cleaning the site

✔✔ c. Using sterile gloves to handle the inner cannula

• Performing care with non-sterile water

A client with a tracheostomy is unable to cough up secretions. What is the appropriate nursing action?✔✔ a. Suction the tracheostomy

• Raise the head of the bed and observe
• Give oral fluids
• Remove the trach tube

What should the nurse do before suctioning a tracheostomy?✔✔ a. Assess oxygen saturation and heart rate

• Lower the head of the bed
• Remove the outer cannula
• Place the client in a side-lying position
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Which of the following should be used to clean the stoma site during routine tracheostomy care?

• Normal saline and alcohol
• Chlorhexidine only

✔✔ c. Normal saline solution

• Hydrogen peroxide only

The nurse is preparing to change the tracheostomy ties. What is the best nursing action?

• Remove both old ties before applying new ones

✔✔ b. Secure new ties before removing old ones

• Wait until the client is asleep to reduce discomfort
• Let the ties fall off naturally

What is the maximum recommended duration for suctioning a tracheostomy?

• 5 seconds
• 20 seconds

✔✔ c. 10 seconds

• 15 seconds
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