The nurse is documenting the completion of tracheostomy suctioning and tracheostomy care in a client's medical record. What should this documentation include?
1. Lung sounds before and after suctioning
2. Characteristics of suctioned sputum
3. Integrity of the skin around the stoma
4. Side on which the tracheostomy tie knot is located
5. Flow rate of oxygen
Correct Answer: 1, 2, 3, 5
Rationale 1: The nurse should document lung sounds before and after suctioning.
Rationale 2: The nurse should document the characteristics of the suctioned sputum.
Rationale 3: The nurse should document the integrity of the skin around the stoma.
Rationale 4: The nurse does not need to document the side on which the tracheostomy tie knot is located.
Rationale 5: The flow rate of the oxygen is not a part of documentation after tracheostomy suctioning or tracheostomy care.
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