Question

The nurse is caring for a spontaneously breathing patient who has a tracheostomy. To determine that the patient can protect the airway when eating without having the tracheostomy cuff inflated, the nurse will deflate the cuff and

a. ask the patient to say a few sentences.
b. monitor for signs of respiratory distress.
c. have the patient drink a small amount of grape juice and observe for coughing.
d. auscultate the lungs for crackles after having the patient take a few sips of water.

Answer 1

To determine if a patient with a tracheostomy can protect their airway while eating with the cuff deflated, the nurse should observe the patient drinking grape juice for any coughing, indicating aspiration risk.

Step-by-step explanation:

When a nurse is caring for a spontaneously breathing patient who has a tracheostomy, to determine if the patient can protect the airway while eating without the tracheostomy cuff inflated, the nurse will deflate the cuff and have the patient drink a small amount of grape juice and observe for coughing. This is to check for aspiration, which would indicate that the patient may not be able to protect their airway effectively when swallowing. Observing the patient's ability to handle liquids without coughing or choking can provide insight into whether the tracheostomy cuff needs to be inflated during meals to prevent food or liquids from entering the lungs, which could lead to aspiration pneumonia.