A patient with a tracheostomy tube expresses concern about the procedure and asks, "Is this going to hurt?”. Which response by the nurse is most appropriate?

"It might hurt a little, but it will be over quickly.".

"You won't feel any pain during the procedure.".

"It's going to be very painful, but it's necessary.".

"Let's administer some pain medication before we start.".

Answer and Explanation

The Correct Answer is A

Choice A rationale:

This response acknowledges the patient's concern and provides a realistic expectation of potential discomfort during the procedure. It offers reassurance that any pain experienced will be brief.

Choice B rationale:

This response is not entirely accurate. While the procedure itself may not cause pain, some patients may experience discomfort during tracheostomy suctioning due to the sensation of suction in the airway.

Choice C rationale:

This response is not appropriate as it exaggerates the potential pain, causing unnecessary distress to the patient.

Choice D rationale:

Administering pain medication solely for the discomfort associated with tracheostomy suctioning is not standard practice. Pain medication should only be given for clinically significant pain or as part of a larger pain management plan.

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Correct Answer is ["C","D","E"]

Explanation

Choice A rationale:

Cleaning the stoma with hydrogen peroxide (Choice A) is not recommended for tracheostomy care. Hydrogen peroxide can be irritating and damaging to the tissues. Normal saline solution should be used to clean the stoma.

Choice B rationale:

Changing the ties or straps every 4 hours (Choice B) is not necessary unless they are soiled or loose. Frequent changes may irritate the skin and increase the risk of infection. Straps should be changed only when needed.

Choice C rationale:

Inspecting the stoma for signs of infection (Choice C) is a crucial step in tracheostomy care. Signs of infection may include redness, swelling, discharge, or foul odor. Prompt identification and treatment of infection are essential to prevent complications.

Choice E rationale:

Applying a new dressing around the stoma and securing it with tape (Choice E) is essential after tracheostomy care to maintain cleanliness and protect the stoma. Proper dressing helps prevent infection and skin breakdown.

Suctioning a tracheostomy tube is a sterile, invasive technique that requires a nurse or a respiratory therapist. It is done to remove secretions from the tube and prevent obstruction, infection, or hypoxia. The steps of suctioning a tracheostomy tube are:

A. How to perform effective oral communication with the tracheostomy tube in place. B. How to use electronic devices for communication in case of emergency. C. How to perform written communication with healthcare providers and family members. D. How to use speaking valves to facilitate speech with the tracheostomy tube in place.

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.

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A patient with a tracheostomy tube expresses concern about the procedure and asks, "Is this going to hurt?”. Which response by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Select all the appropriate steps a nurse should take during tracheostomy care.

Correct Answer is ["C","D","E"]

Explanation

A nurse is educating a patient with a tracheostomy on communication methods. Which information should the nurse include?

Correct Answer is D

Explanation

A nurse is providing care for a patient with a tracheostomy tube. What type of tracheostomy tube would be most suitable for a patient who requires mechanical ventilation or has a high risk of aspiration?

A nurse is suctioning a tracheostomy tube and wants to ensure proper oxygenation between attempts. How long should the nurse wait between each suctioning attempt?

A nurse is preparing to suction a client's tracheostomy tube. Which step should the nurse perform first during the suctioning procedure?

A nurse is preparing to suction a tracheostomy tube for a patient. What position should the nurse place the patient in?

A nurse is providing care for a patient with a tracheostomy who complains of increased coughing, difficulty breathing, and stridor. The nurse assesses that the tracheal lumen has narrowed due to scar formation. Which statement by the nurse is appropriate?

A client has a tracheostomy and is at risk of tracheoesophageal fistula (TEF). Which of the following interventions should the nurse implement to prevent TEF? Select all that apply:

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?

Which statement by the nurse regarding tracheostomy care is correct?