A nurse is about to insert the suction catheter into the patient's tracheostomy tube. The patient says, "I'm feeling anxious about this.”What would be the nurse's appropriate response?
"Don't worry, this won't take long.".
"I understand, but we need to do this to clear your airway.".
"You're going to be just fine, trust me.".
"Let's skip this procedure for now, and we'll try later.".
The Correct Answer is B
Choice A rationale:
This response is dismissive of the patient's feelings and may increase their anxiety. It does not address the patient's concern appropriately.
Choice B rationale:
This response acknowledges the patient's anxiety and provides a clear explanation for the necessity of the procedure. It is empathetic and supportive while also emphasizing the importance of the intervention.
Choice C rationale:
This response is not entirely reassuring and may not be accurate. Simply asking the patient to trust the nurse without explaining the procedure further may not alleviate the patient's anxiety.
Choice D rationale:
Skipping the procedure without a valid reason may compromise the patient's airway and respiratory function. Postponing essential procedures is not appropriate unless there are specific clinical reasons for doing so.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Proceeding with the suctioning as planned when signs of infection are present around the tracheostomy stoma can be detrimental to the patient's health. Suctioning in the presence of infection can exacerbate the infection, spread bacteria, and lead to more serious complications.
Choice B rationale:
Reporting the findings of infection to the healthcare provider is the correct action. The healthcare provider needs to assess the infection and determine the appropriate course of action, such as prescribing antibiotics or adjusting the suctioning regimen to prevent further complications.
Choice C rationale:
Cleaning the area with hydrogen peroxide before suctioning is not recommended. Hydrogen peroxide can be harsh on the skin, and using it around the stoma may cause irritation and delay healing. Moreover, cleaning the area without addressing the infection itself does not address the underlying issue.
Choice D rationale:
Using an antiseptic solution to cleanse the stoma is not the appropriate action in the presence of infection. Antiseptic solutions are designed to prevent infections, not treat existing ones. Using an antiseptic could further irritate the area and delay proper treatment for the infection.
Correct Answer is B
Explanation
Choice A rationale:
A cuffed tracheostomy tube has an inflatable cuff that can create a seal in the trachea, but it also increases the risk of aspiration. In this case, the patient is at low risk of aspiration, so a cuffed tube is not the most suitable choice.
Choice B rationale:
An uncuffed tracheostomy tube lacks an inflatable cuff, which reduces the risk of aspiration. It allows air to flow freely around the tube and is appropriate for patients with a low risk of aspiration, making it the most suitable choice for this patient.
Choice C rationale:
A fenestrated tracheostomy tube has an opening in the posterior wall that allows airflow through the vocal cords, facilitating speech. However, since the patient is already speaking with a low risk of aspiration, a fenestrated tube may not be necessary or the best choice.
Choice D rationale:
A double-lumen tracheostomy tube is designed for independent lung ventilation during certain medical procedures and is not typically used for routine tracheostomy management. It would not be the most suitable choice in this scenario.
Choice E rationale:
Silicone tracheostomy tubes are made of a soft, flexible material that can reduce the risk of tissue damage and provide greater comfort. However, the material of the tracheostomy tube is not the primary consideration for a patient with a low risk of aspiration.
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