Safe, Effective Care Environment
75. Which nursing intervention should be implemented before the deflation of a tracheostomy cuff?
Safe, Effective Care Environment
75. Which nursing intervention should be implemented before the deflation of a tracheostomy cuff?
. Have the obturator available.
. Take a pulse oximetry reading.
. Suction the trachea and mouth.
. Encourage deep breathing and coughing.
Test-Taking Tip
Identify the nursing concept (i.e., to prevent aspiration). Oxygenation (Answers 2 and 4) and replacement of the tracheostomy tube (Answer 1) do not address this concept. All air passages should be free of secretions before deflating a tracheostomy cuff.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Safety and Infection Control/Safe Use of Equipment
Safe, Effective Care Environment
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Answer 1 is incorrect because the tracheostomy should not become dislodged if it is secured with appropriately fitting tracheostomy ties. The obturator should always be at the bedside. Answer 2 is incorrect because the purpose of deflating a tracheostomy cuff is to alleviate pressure and wean the client from the tube. This assessment would be essential if the tracheostomy tube were being removed. Answer 3 is correct because secretions may have pooled above the tracheostomy cuff. If these are not suctioned before deflation, the secretions may be aspirated. Answer 4 is incorrect because, although it is an important intervention for any client with respiratory difficulties, deep breathing and coughing at this time may precipitate additional movement of the tracheostomy tube and bronchospasm.