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 B

Explanation

Choice A rationale:

This response is dismissive of the patient's feelings and may increase their anxiety. It does not address the patient's concern appropriately.

Choice B rationale:

This response acknowledges the patient's anxiety and provides a clear explanation for the necessity of the procedure. It is empathetic and supportive while also emphasizing the importance of the intervention.

Choice C rationale:

This response is not entirely reassuring and may not be accurate. Simply asking the patient to trust the nurse without explaining the procedure further may not alleviate the patient's anxiety.

Choice D rationale:

Skipping the procedure without a valid reason may compromise the patient's airway and respiratory function. Postponing essential procedures is not appropriate unless there are specific clinical reasons for doing so.

A. "I will monitor the cuff pressure to keep it between 20 to 25 cm H2O.". B. "The fenestration should remain open at all times.". C. "The inner cannula is only used when the patient requires mechanical ventilation.". D. "A fenestrated tube is used for patients with a low risk of aspiration.". E. "Metal tracheostomy tubes are commonly used for long-term ventilation.".

Correct Answer is D

Explanation

Choice D rationale:

This statement is correct. A fenestrated tracheostomy tube is designed for patients with a low risk of aspiration and are weaning from mechanical ventilation. The fenestration allows the patient to breathe through the upper airway, promoting speech and facilitating the weaning process. The fenestration can be temporarily occluded to assess the patient's readiness for decannulation.

Choice A rationale:

Monitoring cuff pressure is essential, but the suggested range of 20 to 25 cm H2O is not universally applicable. The appropriate cuff pressure range may vary depending on the patient's condition, and it should be individualized based on the patient's needs.

Choice B rationale:

Keeping the fenestration open at all times is not accurate. The fenestration can be open to allow airflow during weaning and speech therapy, but it can be temporarily occluded when assessing the patient's ability to breathe without the tube.

Choice C rationale:

The inner cannula is not solely used during mechanical ventilation. It is also used for routine cleaning and maintenance of the tracheostomy tube, regardless of the patient's ventilation status.

Choice E rationale:

Metal tracheostomy tubes are not commonly used for long-term ventilation. They are mostly used in specific situations where a plastic tube may not be suitable, such as when there is a risk of tube distortion or damage. Plastic tubes are more commonly used for long-term ventilation due to their availability, flexibility, and ease of use.

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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

A nurse is about to insert the suction catheter into the patient's tracheostomy tube. The patient says, "I'm feeling anxious about this.”What would be the nurse's appropriate response?

Correct Answer is B

Explanation

Which statement by the nurse regarding tracheostomy care is correct?

Correct Answer is D

Explanation

(Select all that apply). A nurse is suctioning a tracheostomy tube for a patient. Which of the following actions are correct during the suctioning process?

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?

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 preparing to perform tracheostomy care for a patient. What is the recommended interval for performing tracheostomy care?

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 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 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 client with a tracheostomy is at risk of developing tracheomalacia. Which statement by the client indicates a need for further education?