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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Positioning the patient in semi-Fowler's position (Choice A) is an important step in tracheostomy care, but it is not the first step during the suctioning procedure. Semi-Fowler's position helps promote lung expansion and allows for better visualization during the procedure.
Choice B rationale:
Applying a new dressing around the stoma (Choice B) is essential after suctioning to maintain cleanliness and prevent infection. However, it is not the first step in the suctioning procedure. The nurse should first gather the necessary equipment.
Choice C rationale:
Cleaning the inner cannula with hydrogen peroxide (Choice C) is not the first step during suctioning. The nurse should gather equipment and supplies first before performing any cleaning or other procedures.
Choice E rationale:
Removing the old dressing and discarding it in a moisture-resistant bag (Choice E) is an important step, but it should come after the nurse gathers the necessary equipment for the suctioning procedure.
Correct Answer is B
Explanation
Choice A rationale:
While notifying the healthcare provider is essential, the priority action in this situation is to stop the bleeding to prevent further complications.
Choice B rationale:
Applying direct pressure to the tracheostomy stoma is the first action the nurse should take to control the bleeding and stabilize the patient.
Choice C rationale:
Administering fluids and blood products may be necessary later, but it is not the first action to take when dealing with active bleeding.
Choice D rationale:
Ensuring proper positioning and alignment of the tracheostomy tube is important, but it is not the priority in this critical situation.
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