A nurse is about to perform sterile suctioning and asks the patient if they are ready. The patient responds, "I am feeling very anxious about this.” What would be the appropriate response from the nurse?
"Don't worry; it won't take long.”
"We can postpone the procedure if you prefer.”
"I understand. Let's proceed, and I'll explain each step.”
"Suctioning is routine; you'll be fine once it's done.”
The Correct Answer is C
Choice C rationale:
The nurse should acknowledge the patient's anxiety and respond empathetically. Assuring the patient that the nurse will explain each step during the procedure can help alleviate anxiety. This approach promotes trust and helps the patient feel more in control, which is important for patient cooperation during the suctioning procedure.
Choice A rationale:
Telling the patient not to worry and that it won't take long may come across as dismissive and not address the patient's concerns adequately.
Choice B rationale:
Offering to postpone the procedure is an option, but the nurse should first attempt to address the patient's anxiety and provide reassurance. If the anxiety persists despite the explanation, postponing the procedure can be considered.
Choice D rationale:
Dismissing the patient's anxiety by stating that suctioning is routine may not effectively address the patient's feelings and may not be comforting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Cleaning the inner cannula once a week is insufficient to maintain proper hygiene for a patient with a tracheostomy tube. The inner cannula should be cleaned more frequently, as directed by the healthcare provider, to prevent the accumulation of secretions and potential respiratory complications.
Choice B rationale:
Deflating the cuff before cleaning the tracheostomy tube is not recommended because it may lead to aspiration of secretions or loss of the airway seal. The cuff should only be deflated when it is necessary to remove or change the tracheostomy tube.
Choice C rationale:
Using cotton-tipped applicators to clean the stoma is not the recommended method for tracheostomy care. Sterile tracheostomy care kits usually include specialized brushes or swabs designed for this purpose, ensuring effective and safe cleaning of the stoma without the risk of shedding fibers or causing injury.
Choice D rationale:
Changing the tracheostomy ties every 24 hours is the appropriate action. Regular changing of the ties helps prevent complications such as skin breakdown, ensures a secure fit of the tracheostomy tube, and reduces the risk of infection.
Correct Answer is C
Explanation
To assess lung sounds.
Choice A rationale:
Sterile suctioning is not performed to administer medications. Its primary purpose is to remove secretions and maintain a patent airway.
Choice B rationale:
Sterile suctioning is not done solely for promoting comfort. Its main goal is to clear the airway and prevent respiratory complications.
Choice C rationale:
The purpose of sterile suctioning is to assess lung sounds by removing excess secretions and mucus that may obstruct the airway. This helps in evaluating the patient's respiratory status and identifying any abnormal lung sounds.
Choice D rationale:
Sterile suctioning is not performed to monitor vital signs. Although vital signs may be monitored during the procedure, it is not the primary purpose of suctioning.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.