Question

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse would cause the charge nurse to intervene?

a) Assessing the tracheostomy site for signs of bleeding or swelling.
b) Providing oral care every 2 hours to maintain a clean environment.
c) Suctioning the tracheostomy when there are audible secretions.
d) Changing the tracheostomy ties daily to ensure cleanliness.

Answer 1

The correct action by the nurse that would cause the charge nurse to intervene is providing oral care every 2 hours to maintain a clean environment.

Step-by-step explanation:

The correct action by the nurse that would cause the charge nurse to intervene is option b) Providing oral care every 2 hours to maintain a clean environment.

After a tracheostomy, it is important to avoid introducing anything into the trachea to prevent complications and infections. Performing oral care on a client with a tracheostomy can introduce secretions and bacteria into the trachea, which can lead to an infection.

Instead of providing oral care, the nurse should focus on assessing the tracheostomy site for signs of bleeding or swelling (option a), suctioning the tracheostomy when there are audible secretions (option c), and changing the tracheostomy ties daily to ensure cleanliness (option d).