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.”

Answer and Explanation

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.

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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.

A. "I have some mild nasal congestion.". B. "My throat feels a bit sore.". C. "I have been coughing up blood.". D. "I feel a little lightheaded.".

Correct Answer is C

Explanation

"I have been coughing up blood.”.

Choice A rationale:

Mild nasal congestion may be a common finding in many patients and does not necessarily contraindicate suctioning unless it significantly obstructs the airway.

Choice B rationale:

A sore throat may indicate local irritation, but it does not directly contraindicate suctioning unless there are other underlying complications.

Choice C rationale:

A history of coughing up blood (hemoptysis) suggests an ongoing bleeding disorder. Suctioning could exacerbate the bleeding, leading to further complications. The procedure should be avoided until the cause of hemoptysis is properly assessed and managed.

Choice D rationale:

Feeling lightheaded may be a common sensation during and after suctioning due to the stimulation of the gag reflex, but it does not necessarily contraindicate the procedure. It is essential to ensure adequate oxygenation and provide proper support during the procedure to minimize this discomfort.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing tracheostomy care for a patient with a tracheostomy tube (TT). Which action should the nurse include in the procedure?

Correct Answer is D

Explanation

A client with a history of bleeding disorder requires suctioning. Which statement indicates that the nurse should not proceed with the procedure?

Correct Answer is C

Explanation

A nurse is preparing to perform sterile suctioning on a patient. What should be the nurse's priority action before suctioning?

(Select all that apply): A client requires sterile suctioning through a tracheostomy tube (TT). What steps should the nurse follow during the suctioning procedure? Select all that apply.

A client expresses concern about the suctioning procedure. What is the best response by the nurse?

(Select all that apply - Online ATI/HESI question): A nurse is performing sterile suctioning on a patient. Which of the following are appropriate infection control measures for this procedure? Select all that apply.

(Select all that apply): A nurse is preparing to perform nasopharyngeal suctioning for a patient with a nasopharyngeal tube (NPT). What actions should the nurse take during the procedure? Select all that apply.

A client is undergoing sterile suctioning. Which interventions should the nurse implement during the suctioning procedure? Select all that apply.

A nurse has completed sterile suctioning for a patient with an endotracheal tube (ETT). What should the nurse do next?

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?