Airway and ventilation questions reward the nurse who protects oxygenation first and follows sterile technique. Work through these 10 practice questions on suctioning, tracheostomy care and emergencies, ventilator alarms and VAP prevention, chest tubes, and oxygen delivery, each with a full rationale.
Airway Management: Suctioning, Trach Care, Vent Alarms & VAP
Airway and ventilation items reward a nurse who protects oxygenation first and follows sterile, evidence-based technique. For tracheal suctioning, use sterile technique, hyperoxygenate with 100% oxygen before and after, and apply suction ONLY while withdrawing the catheter using intermittent suction. Limit each pass to 10-15 seconds, allow recovery between passes, and stop for hypoxia, bradycardia, or new dysrhythmias. Do not routinely instill saline. For tracheostomy care, always keep the obturator plus a spare same-size tube (and one a size smaller) at the bedside. If a MATURE stoma tube dislodges, reinsert with the obturator; if a FRESH trach (roughly within 7 days) dislodges, it is an emergency—call for help, do not force blind reinsertion, cover the stoma, and bag-mask ventilate over the mouth/nose (or stoma). Maintain cuff pressure at 20-30 cmH2O, humidify inspired air (the trach bypasses the upper airway), keep the inner cannula and stoma clean, and secure ties allowing one finger underneath.
On a ventilator, confirm ET tube placement with an end-tidal CO2 detector and chest x-ray. Master the alarms: a HIGH-pressure alarm means increased resistance or decreased compliance—secretions (suction), kinked or bitten tubing, water in the circuit, coughing, or bronchospasm. A LOW-pressure alarm means a leak or disconnection—check every connection and reconnect. Prevent ventilator-associated pneumonia with the bundle: head of bed 30-45 degrees, regular oral care (chlorhexidine has been the classic bundle element, though the 2022 SHEA/IDSA update no longer recommends routine chlorhexidine and favors daily toothbrushing), a daily sedation vacation with readiness-to-wean assessment, and DVT plus peptic-ulcer prophylaxis.
For chest tubes, gentle tidaling is normal but CONTINUOUS bubbling in the water-seal chamber suggests an air leak. If tubing DISCONNECTS, submerge the chest-tube end in sterile water; if the tube is pulled OUT of the chest, apply a sterile occlusive dressing taped on three sides. Do not routinely clamp a chest tube. For oxygen, match the device to the need: low-flow (nasal cannula, simple mask, non-rebreather) versus high-flow, where a Venturi mask delivers a precise FiO2; humidify higher flows.
Respiratory Procedures & Airway Management NCLEX Practice Questions
Question 1 · Airway Suctioning
A nurse is performing endotracheal suctioning on an adult client. Which action reflects correct technique?
- A Apply continuous suction as the catheter is advanced into the airway.
- B Suction for 30 seconds on each pass to fully clear thick secretions.
- C Apply intermittent suction only while withdrawing the catheter.
- D Instill 10 mL of normal saline before each pass to loosen secretions.
Show answer & rationale
Correct answer: C
Suction is applied only intermittently and only while withdrawing the catheter. Suctioning on insertion strips oxygen from the airway and traumatizes the mucosa without clearing secretions, so applying continuous suction as the catheter is advanced is unsafe. Each pass should last no more than 10-15 seconds; suctioning for 30 seconds causes profound hypoxia, bradycardia, and vagal-mediated dysrhythmias because the client cannot ventilate while the catheter occludes the airway. Routinely instilling normal saline is no longer recommended—it does not thin secretions, can push contaminants into the lower airway, and drops oxygen saturation; adequate systemic hydration and airway humidification are the correct way to mobilize secretions. Correct practice: use sterile technique, hyperoxygenate with 100% oxygen before and after, insert the catheter without suction, then apply intermittent suction while rotating and withdrawing, limiting the pass to 10-15 seconds and allowing recovery between no more than 2-3 passes. Clinical pearl: 'In without suction, out with suction'—and count the pass like a breath hold; if you can't hold your own breath comfortably that long, neither can your client. Stop immediately for a heart rate drop, desaturation, or new dysrhythmia and reoxygenate.
Question 2 · Tracheostomy Care
A well-established (mature) tracheostomy tube is accidentally dislodged while the nurse is changing the ties. The client is breathing but anxious. What is the nurse's priority action?
- A Reinsert the tube with its obturator, then remove the obturator.
- B Cover the stoma with an occlusive dressing and wait for the provider.
- C Suction the stoma repeatedly before any attempt to reinsert the tube.
- D Push the old tube back in without the obturator to save time.
Show answer & rationale
Correct answer: A
With a mature (well-healed, generally more than 7 days old) stoma, the tract is established, so the nurse reinserts the tube using the obturator, which provides a smooth, rounded tip that guides the tube through the tract without catching soft tissue. The obturator occludes the lumen during insertion, so it must be removed immediately afterward to allow airflow, then the inner cannula is inserted. Covering the stoma with an occlusive dressing and simply waiting would obstruct the airway of a client who breathes through that stoma and delays reestablishing the airway. Repeatedly suctioning the stoma before reinsertion wastes time, provides no ventilation, and can worsen hypoxia; reestablishing the airway comes first. Forcing the tube in without the obturator risks creating a false passage into the soft tissue and mediastinum and can convert a manageable event into an emergency. Clinical pearl: keep the obturator AND a spare same-size tube (plus one a size smaller) taped to the wall at every trach bedside—the obturator is your reinsertion tool for a mature stoma, and the size-smaller tube is your backup if the stoma has narrowed. Remember the sequence: obturator in for insertion, obturator out, inner cannula in, confirm air movement and breath sounds.
Question 3 · Tracheostomy Emergency
A tracheostomy was surgically created 3 days ago. The tube becomes completely dislodged and the client develops respiratory distress. Immediate reinsertion is unsuccessful. What should the nurse do?
- A Make repeated blind attempts to reinsert the tube until it slides into the stoma.
- B Clamp the stoma closed and place the client in the prone position until help arrives.
- C Withhold all oxygen until the surgeon arrives at the bedside to reinsert the tube.
- D Call for help and bag-mask ventilate over the mouth and nose, covering the stoma.
Show answer & rationale
Correct answer: D
A tracheostomy less than about 7 days old is a fresh, immature stoma with no established tract, so accidental decannulation is an emergency. When reinsertion is not immediately successful, the nurse calls for help (rapid response/provider) and maintains oxygenation. Because the upper airway is still patent in most fresh trachs, the nurse can ventilate with a bag-mask over the mouth and nose while occluding the stoma with a gloved hand or gauze to prevent air escape; if the client cannot be oxygenated that way, a mask can be applied over the stoma itself. Repeated blind reinsertion attempts are dangerous—the tube can be forced into a false tract in the soft tissues or mediastinum, causing bleeding, subcutaneous emphysema, and complete loss of the airway. Clamping the stoma and proning does nothing to oxygenate and can worsen distress. Withholding all oxygen while waiting is never acceptable; the client will become hypoxic and arrest. Clinical pearl: 'Fresh trach out = call, cover, and bag from above.' Mature stoma = obturator reinsertion; fresh stoma = do not force it, oxygenate by mask over mouth/nose (covering the stoma) or over the stoma, and get expert help fast.
Question 4 · Mechanical Ventilation Alarms
The high-pressure alarm on a mechanically ventilated client sounds. The client is coughing and coarse crackles are auscultated bilaterally. What is the nurse's best initial action?
- A Check the circuit for a disconnection and reconnect any loose tubing.
- B Suction the client's airway to clear secretions.
- C Add sterile water to the humidifier reservoir.
- D Decrease the set tidal volume on the ventilator.
Show answer & rationale
Correct answer: B
A high-pressure alarm signals increased airway resistance or decreased lung compliance. Coughing with coarse crackles points to secretions in the airway, so the nurse suctions to clear them. Other high-pressure causes include kinked or bitten tubing, water pooled in the circuit, bronchospasm, and the client biting the tube—assess and correct the trigger. Checking for a disconnection and reconnecting tubing is the response to a LOW-pressure alarm (a leak or disconnection lowers circuit pressure), not a high-pressure alarm, so it addresses the wrong problem here. Adding water to the humidifier does not relieve airway obstruction and, if anything, condensation pooling in the tubing is itself a high-pressure trigger. Decreasing the set tidal volume masks the alarm by lowering delivered volume rather than fixing the resistance, and altering ventilator settings is not an independent nursing action without a provider order; it also risks hypoventilation. Clinical pearl: HIGH pressure = something is Harder to push air IN (secretions, kink, bite, bronchospasm, water)—so look at the client and tubing and suction if you hear secretions. LOW pressure = air is Leaking OUT (disconnection or cuff leak)—reconnect and check the cuff. Never simply silence an alarm without finding and fixing the cause.
Question 5 · Mechanical Ventilation Alarms
A low-pressure ventilator alarm sounds on a client receiving mechanical ventilation. Which finding is the most likely cause?
- A Kinking of the ventilator tubing under the side rail.
- B Thick secretions partially obstructing the endotracheal tube.
- C The client biting down on the endotracheal tube while agitated.
- D A disconnection between the endotracheal tube and the circuit.
Show answer & rationale
Correct answer: D
A low-pressure alarm indicates that circuit pressure has fallen below the set threshold, which happens when air is escaping—most commonly a disconnection somewhere in the circuit or a cuff leak. The nurse should immediately trace and check every connection and reconnect the tubing; if no disconnection is found, evaluate for an endotracheal tube cuff leak (an audible gurgle or the client vocalizing suggests the cuff is underinflated or ruptured). Kinked tubing, thick secretions obstructing the tube, and the client biting the tube all INCREASE resistance to airflow and therefore trigger the HIGH-pressure alarm, not the low-pressure alarm. Clinical pearl: LOW pressure = a Leak (disconnection or cuff leak); HIGH pressure = a block/resistance (secretions, kink, bite, bronchospasm, water in tubing). If you ever cannot quickly identify and fix the cause and the client is compromised, disconnect from the ventilator and manually ventilate with a bag-valve device delivering 100% oxygen while calling for help. Always confirm initial ET tube placement with an end-tidal CO2 detector and chest x-ray so that a later alarm points you to a circuit issue rather than a malpositioned tube.
Question 6 · Chest Tubes
A nurse discovers that a client's chest tube has become disconnected from the drainage system. Until a new drainage unit can be set up, what should the nurse do?
- A Clamp the chest tube close to the insertion site.
- B Cover the chest insertion site with a dressing taped on three sides.
- C Submerge the end of the chest tube in a bottle of sterile water.
- D Lay the disconnected tubing flat on the bed and notify the provider.
Show answer & rationale
Correct answer: C
When a chest tube becomes disconnected from the drainage system, the nurse submerges the open end of the chest tube in a bottle of sterile water. This re-creates a water seal so air can leave the pleural space on exhalation but cannot be drawn back in on inhalation, preventing a pneumothorax while a new system is assembled. Clamping the chest tube is not done routinely and is dangerous here—if air continues to enter the pleural space with nowhere to escape, a tension pneumothorax can develop. A dressing taped on three sides is the intervention when the tube is accidentally pulled OUT of the chest (the flutter-valve dressing lets trapped air escape while limiting air entry)—but the tube here is still in the chest and only disconnected from the drainage unit, so an occlusive dressing does not apply. Simply laying the tubing flat leaves the pleural space open to atmospheric air, allowing lung collapse. Clinical pearl: disconnected FROM the system = 'water seal in a water bottle' (submerge in sterile water); tube OUT of the CHEST = occlusive dressing taped on three sides. Also remember that continuous bubbling in the water-seal chamber signals an air leak, while gentle tidaling is expected and normal.
Question 7 · Oxygen Delivery
A client with COPD requires a precise, controlled fraction of inspired oxygen (FiO2) to avoid suppressing the respiratory drive. Which oxygen delivery device best meets this need?
- A Nasal cannula
- B Venturi mask
- C Simple face mask
- D Non-rebreather mask
Show answer & rationale
Correct answer: B
The Venturi mask is a high-flow device that entrains room air at a fixed ratio, delivering the most precise and consistent FiO2 (commonly 24%-50% depending on the color-coded adapter). This exact control makes it the preferred choice when titrating oxygen carefully, such as in COPD where excessive oxygen can blunt the hypoxic drive and worsen CO2 retention. A nasal cannula is a low-flow device whose delivered FiO2 varies widely with the client's respiratory rate, tidal volume, and mouth breathing, so it cannot guarantee a set concentration. A simple face mask is also low-flow and delivers a variable, higher range (roughly 40%-60%) that is not precisely controlled. A non-rebreather mask delivers the highest concentration (up to about 90%-100%) and is used for emergencies and acute hypoxemia, but it provides a high, imprecise FiO2—exactly what you want to avoid when careful titration is required. Clinical pearl: think 'Venturi = Very precise.' Match the device to the goal—non-rebreather for a crashing, acutely hypoxemic client; Venturi when you need a specific, controlled FiO2 like in a chronic CO2 retainer. Remember to humidify oxygen at higher flow rates to prevent drying of the airway mucosa.
Question 8 · Airway Suctioning
A nurse is preparing to perform tracheal suctioning on an adult client with a tracheostomy. Which actions are appropriate? Select all that apply.
- A Apply suction while inserting the catheter so secretions are reached faster.
- B Hyperoxygenate the client with 100% oxygen before and after suctioning.
- C Limit each suction pass to 10-15 seconds.
- D Use clean, non-sterile technique for deep tracheal suctioning.
- E Allow the client to recover and reoxygenate between passes.
- F Monitor for bradycardia and new dysrhythmias during the procedure.
Show answer & rationale
Correct answer: B, C, E, F
Correct actions: hyperoxygenate with 100% oxygen before and after suctioning to build an oxygen reserve; limit each pass to 10-15 seconds to minimize hypoxia; monitor for bradycardia and dysrhythmias, which arise from vagal stimulation and hypoxia; and allow recovery between passes (no more than 2-3 passes) so saturation and heart rate return to baseline. Incorrect actions: deep tracheal suctioning requires STERILE technique, not clean technique, because the catheter enters the lower airway below the body's natural defenses—clean technique is reserved for oral (Yankauer) suctioning of the mouth. Applying suction while inserting the catheter is wrong; suction is applied only while withdrawing, because suctioning on insertion removes oxygen, traumatizes mucosa, and does not clear secretions any faster. Clinical pearl: remember the safety bundle as 'oxygenate, sterile, in-without-suction, out-with-suction, 10-15 seconds, watch the monitor, rest.' Stop immediately and reoxygenate if the heart rate drops, oxygen saturation falls, or the rhythm changes. Adequate hydration and airway humidification—not routine saline instillation—are what actually keep secretions thin and mobilizable.
Question 9 · VAP Prevention
A nurse is caring for a client on mechanical ventilation. Which interventions are part of the ventilator-associated pneumonia (VAP) prevention bundle? Select all that apply.
- A Keep the client flat and supine to prevent aspiration.
- B Elevate the head of the bed 30-45 degrees.
- C Provide oral care with chlorhexidine.
- D Perform a daily sedation vacation with a readiness-to-wean assessment.
- E Instill normal saline into the endotracheal tube every 2 hours.
- F Provide DVT and peptic-ulcer (stress ulcer) prophylaxis.
Show answer & rationale
Correct answer: B, C, D, F
The VAP bundle components here are: elevating the head of the bed 30-45 degrees to reduce aspiration of gastric and oral secretions; oral care with chlorhexidine to decrease colonization with pathogenic bacteria (the classic bundle answer, although the 2022 SHEA/IDSA update no longer recommends routine chlorhexidine and emphasizes daily toothbrushing); a daily sedation vacation paired with a readiness-to-wean (spontaneous breathing) assessment so the client is extubated as early as safely possible, shortening ventilator days; and DVT plus peptic-ulcer prophylaxis, which are classic ventilator-bundle elements that protect the critically ill client from clots and GI bleeding rather than preventing pneumonia itself. Keeping the client flat and supine is incorrect and directly opposite the bundle—it promotes aspiration and pneumonia, so the head of the bed should be UP, not flat. Routinely instilling normal saline into the endotracheal tube every 2 hours is not recommended; it does not thin secretions, can dislodge biofilm and bacteria into the lower airway, and lowers oxygen saturation. Clinical pearl: remember VAP prevention as 'Heads up, mouth clean, wake and wean, clots and ulcers covered.' The single most emphasized nursing action is head-of-bed elevation, because it is low-cost, independent, and highly effective at reducing aspiration risk. The best way to prevent VAP overall is to liberate the client from the ventilator as soon as clinically safe.
Question 10 · Tracheostomy Care
A nurse is providing care for a client with a newly established tracheostomy. Which measures are appropriate? Select all that apply.
- A Keep the obturator and a spare same-size tracheostomy tube at the bedside.
- B Withhold humidification because the tracheostomy adequately warms inspired air.
- C Provide humidification to inspired air.
- D Maintain tracheostomy cuff pressure at 20-30 cmH2O.
- E Secure the ties tightly so that no finger can fit underneath.
- F Keep the inner cannula and the stoma clean.
Show answer & rationale
Correct answer: A, C, D, F
Appropriate measures: keep the obturator plus a spare same-size tube (and one a size smaller) at the bedside for emergency reinsertion; maintain cuff pressure at 20-30 cmH2O (measured with a cuff manometer) to seal the airway while preventing tracheal mucosal ischemia and necrosis from overinflation; provide humidification because the tracheostomy bypasses the nose and mouth, which normally warm and moisten inspired air—without added humidity, secretions thicken and can plug the tube; and keep the inner cannula and stoma clean to prevent obstruction and infection. Incorrect: withholding humidification is wrong precisely because the trach bypasses the upper airway, so supplemental humidification is essential. Securing the ties so tightly that no finger fits underneath is wrong—ties should be snug but allow one finger to slide underneath, preventing skin breakdown, venous congestion, and airway compression. Clinical pearl: 'Obturator and spare tube always at the bedside; cuff 20-30 cmH2O; one finger under the ties; humidify because you bypassed the nose.' Overinflated cuffs (greater than about 30 cmH2O) compress capillaries and cause tracheal wall damage and fistula formation, so cuff pressure should be checked routinely. When two provided choices directly contradict each other—here, humidify versus withhold humidification—one is the answer and one is the distractor, so reason from the physiology: the trach bypasses natural humidification, so you must add it.
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Respiratory Procedures & Airway FAQ
How long should you suction a tracheostomy or endotracheal tube?
Limit each suction pass to 10-15 seconds and perform no more than 2-3 passes, allowing the client to recover and reoxygenate between passes. Hyperoxygenate with 100% oxygen before and after, use sterile technique for deep suctioning, and apply suction only while withdrawing the catheter. Stop immediately if the heart rate drops, oxygen saturation falls, or new dysrhythmias appear.
What is the difference between a high-pressure and a low-pressure ventilator alarm?
A high-pressure alarm means increased airway resistance or decreased compliance—think secretions (suction), a kinked or bitten tube, water in the tubing, coughing, or bronchospasm. A low-pressure alarm means a leak or disconnection—check all connections, reconnect the circuit, and assess for a cuff leak. Memory aid: high pressure = something is blocking air going in; low pressure = air is leaking out.
What should you do if a tracheostomy tube falls out?
It depends on the age of the stoma. For a mature, well-healed tracheostomy, reinsert the tube using the obturator, then remove the obturator and insert the inner cannula. For a fresh tracheostomy (roughly within 7 days), it is an emergency: call for help, do not force blind reinsertion, cover the stoma, and ventilate with a bag-mask over the mouth and nose (occluding the stoma) or over the stoma itself.
What do you do if a chest tube gets disconnected or pulled out?
If the tube disconnects from the drainage system, submerge the open end in a bottle of sterile water to restore a water seal. If the tube is pulled completely out of the chest, cover the site with a sterile occlusive dressing taped on three sides so trapped air can escape. Do not routinely clamp a chest tube, and remember that continuous bubbling in the water-seal chamber signals an air leak.