The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance?
a. Suctioning respiratory secretions several times every hour
b. Administering humidified oxygen through a tracheostomy collar
c. Instilling normal saline into the tracheostomy to thin secretions before suctioning
d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions
ANS: B
Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying of secretions that cause occlusion. Suctioning should be done only as needed; too frequent suctioning can damage the mucosal lining, resulting in thicker secretions. Normal saline should not be instilled into a tracheostomy; research showed no benefit with this technique. The purpose of the tracheostomy cuff is to keep secretions from entering the lungs; the nurse should not deflate the tracheostomy cuff unless instructed to do so by the health care provider.
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