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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale:
Maintaining proper cuff pressure prevents pressure-related injuries and potential tracheoesophageal fistula (TEF) formation.
Choice B rationale:
Progressing to a deflated cuff or cuffless tube reduces the risk of TEF by minimizing pressure on the tracheal tissues.
Choice C rationale:
Tracheal dilation or surgical intervention may be necessary if TEF has already developed but is not a preventive measure.
Choice D rationale:
Using a small soft feeding tube instead of a nasogastric tube for tube feedings reduces the risk of trauma to the tracheal tissues and lowers the risk of TEF formation.
Choice E rationale:
Administering oxygen by mask may be necessary for oxygenation, but it is not specifically related to preventing tracheoesophageal fistula formation.
Correct Answer is C
Explanation
Choice A rationale:
This choice is not appropriate because increased coughing, difficulty breathing, and stridor suggest a mechanical issue rather than an infection. Monitoring for fever or increased secretions is not addressing the potential cause of the symptoms.
Choice B rationale:
This choice is not appropriate for the presented situation. Expectorating secretions may not directly address the narrowed tracheal lumen due to scar formation, and it is not the primary intervention needed.
Choice C rationale:
This is the correct choice. Ensuring the tracheostomy tube is securely positioned in the midline can help prevent further narrowing of the tracheal lumen. Proper alignment and securing of the tube can optimize airflow and reduce complications related to scar formation.
Choice D rationale:
Using a larger tracheostomy tube may not be the most appropriate action in this situation. Enlarging the tube may not be necessary and could potentially cause other complications. It's better to ensure proper positioning and consider other interventions before resorting to a larger tube.
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