A nurse is preparing to suction a patient's tracheostomy tube and observes signs of infection around the stoma. What action should the nurse take?
Proceed with the suctioning as planned.
Report the findings to the healthcare provider.
Clean the area with hydrogen peroxide before suctioning.
Use an antiseptic solution to cleanse the stoma.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
This choice is not the most relevant information for the patient with a tracheostomy regarding communication methods. Effective oral communication with the tube in place may be challenging, and other options should be explored.
Choice B rationale:
While electronic devices can be helpful for communication, they may not be the most practical option for a patient with a tracheostomy, especially during emergencies when devices may not be readily available.
Choice C rationale:
This choice is somewhat relevant but not the most appropriate. While written communication is an option, it may not be the primary method used with a tracheostomy.
Choice D rationale:
This is the correct choice. Teaching the patient how to use speaking valves to facilitate speech with the tracheostomy tube in place can significantly improve communication. Speaking valves allow airflow during inhalation and redirect exhaled air through the vocal cords, enabling speech while maintaining a closed respiratory system during exhalation. This is a valuable communication method for patients with tracheostomies.
Correct Answer is C
Explanation
Choice A rationale:
Administering antibiotics would be indicated if the patient develops a respiratory infection, but it would not directly address the issue of dry and crusted secretions.
Choice B rationale:
Increasing suction frequency may help remove secretions, but it may also lead to increased irritation and trauma to the tracheal lining. It is not the first-line intervention for dry and crusted secretions.
Choice C rationale:
Providing humidification and hydration helps to moisten the secretions, making them easier to expectorate or suction. It is the most appropriate intervention to address dry and crusted secretions in a patient with a tracheostomy tube.
Choice D rationale:
Performing daily tracheostomy tube changes is not indicated solely to address dry and crusted secretions unless there is a specific problem with the current tube that requires changing.
Choice E rationale:
Recommending a fenestrated tracheostomy tube would not directly address the issue of dry and crusted secretions. Fenestrated tubes are more relevant for patients who need speech assistance, which is not the primary concern in this case.
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