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    Fundamentals11 min read

    NCLEX Tracheostomy and Airway Management Questions

    Airway is the first letter of ABC for a reason. These items test whether you can suction safely, care for a new tracheostomy and respond when the tube comes out.

    Quick answer

    On NCLEX airway items, suction only when indicated rather than on a schedule, apply suction for no longer than 10–15 seconds, use 80–120 mmHg of wall suction for adults, apply suction only while withdrawing the catheter, and hyperoxygenate before and after. If a tracheostomy tube is accidentally dislodged, hold the stoma open with a curved haemostat and insert the spare tube kept at the bedside.

    Key takeaways

    • Suction is indicated by assessment findings, not by the clock.
    • Adult suction pressure 80–120 mmHg; each pass 10–15 seconds maximum.
    • Never apply suction while inserting the catheter — only while withdrawing.
    • Keep an obturator and a spare tracheostomy tube (same size and one smaller) at the bedside.
    • Humidification is essential because the upper airway is bypassed.
    • New tracheostomy ties are changed with two people; never cut the old tie first alone.

    When to suction and how to do it safely

    The single most tested principle in airway questions is that suctioning is done for a reason, not on a schedule. Correct indications include audible or auscultated coarse crackles or gurgling, visible secretions in the tube, increased peak airway pressures on a ventilator, decreased oxygen saturation, restlessness, and an ineffective cough. A stem that offers 'suction every two hours' as a routine order should trigger suspicion.

    Technique details are heavily tested because each one prevents a specific complication. Hyperoxygenate before and after to prevent hypoxaemia. Insert the catheter without suction applied so you do not strip oxygen and damage mucosa on the way in. Apply intermittent suction while withdrawing and rotating, and limit each pass to 10–15 seconds. Allow the client to rest and re-oxygenate between passes, and limit the total to about three passes.

    Complications to watch for during and after suctioning include hypoxaemia, bradycardia from vagal stimulation, dysrhythmias, mucosal trauma with bloody secretions, and raised intracranial pressure in neurologically injured clients. If the heart rate drops or the saturation falls significantly, stop suctioning and oxygenate.

    • Assess first: breath sounds, saturation, secretions, work of breathing
    • Hyperoxygenate before and after each suctioning episode
    • No suction on insertion; intermittent suction on withdrawal
    • 10–15 seconds per pass, maximum of about three passes
    • Stop for bradycardia, desaturation or new dysrhythmias

    Routine tracheostomy care

    Tracheostomy care questions test sterile versus clean technique, the order of steps, and safety equipment. In the acute care setting, tracheostomy care and suctioning are performed using sterile technique. The inner cannula is removed and either cleaned or replaced with a disposable one, the stoma is cleaned with normal saline working from the stoma outward, and a pre-cut or manufactured drain sponge is used because cutting gauze creates loose fibres that can be aspirated.

    Ties are changed with a second person holding the tube in place, and the new tie is secured before the old one is removed. This detail appears in SATA items constantly because removing the old tie first risks decannulation. Tightness is judged by fitting one or two fingers under the tie.

    Because a tracheostomy bypasses the nose and mouth, inspired air is neither warmed nor humidified. Supplemental humidification prevents thick secretions and mucous plugging, and adequate hydration supports the same goal. Expect items where the correct action for tenacious secretions is to increase humidification and fluids rather than to suction more aggressively.

    Tracheostomy bedside safety equipment and why it matters
    ItemPurpose
    ObturatorGuides reinsertion of the same tube
    Spare tube, same sizeImmediate replacement if dislodged
    Spare tube, one size smallerUsed if the stoma has narrowed and the same size will not pass
    Curved haemostatHolds the stoma open during reinsertion
    Suction equipment and cathetersClears obstructing secretions
    Manual resuscitation bagVentilation if the airway is lost

    Airway emergencies

    Accidental decannulation is the classic emergency item. If the tube comes out within the first 72 hours after surgical placement, the tract is immature and the priority is to maintain the airway: hold the stoma open with a curved haemostat, attempt to insert the spare tube with the obturator, remove the obturator immediately after insertion so air can pass, and call for help. If reinsertion fails, cover the stoma and ventilate with a bag-valve-mask over the mouth and nose while summoning emergency assistance.

    Mucous plugging presents as sudden respiratory distress with no air movement through the tube. The sequence is to attempt suctioning first, and if the catheter will not pass, remove the inner cannula because the plug is often lodged there. Only if these fail is the outer tube changed.

    Cuff management appears in ventilated-client items. An inflated cuff prevents aspiration and allows positive pressure ventilation, but excessive pressure causes tracheal ischaemia; cuff pressure is generally maintained around 20–25 mmHg. A client who can speak with a cuffed tube inflated may have a cuff leak, which is a finding to investigate rather than to ignore.

    How airway content shows up across the exam

    Airway is not confined to fundamentals. It appears in prioritization questions where an airway problem outranks circulation and pain, in delegation questions where suctioning an unstable client cannot be delegated to unlicensed personnel, and in paediatric items where smaller tubes obstruct faster. Whenever a stem gives you several problems, scan for airway compromise first.

    Practise by working through fundamentals sets and management of care sets side by side, and note how often the correct answer is simply to assess or protect the airway before anything else.

    Frequently asked questions

    How long should each suction pass last?

    No more than 10–15 seconds of applied suction per pass, with oxygenation and rest between passes and a limit of roughly three passes. Longer suctioning causes hypoxaemia, bradycardia and mucosal trauma.

    What suction pressure is safe for adults?

    Wall suction of about 80–120 mmHg for adults. Higher pressures increase mucosal injury and bleeding without improving secretion clearance; paediatric and neonatal ranges are lower.

    What do I do first if a tracheostomy tube falls out?

    Maintain the airway. Hold the stoma open with a curved haemostat and insert the spare tube using the obturator, removing the obturator immediately after placement. If you cannot reinsert, cover the stoma and ventilate with a bag-valve-mask over the mouth and nose while calling for emergency help.

    Can suctioning be delegated to unlicensed assistive personnel?

    Generally no for unstable clients or new tracheostomies. Suctioning an established, stable tracheostomy may be delegated in some settings per facility policy, but assessment of breath sounds and the decision to suction remain with the registered nurse.