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:

A neonate with a tracheostomy tube would require lower suction pressure compared to an adult. Neonates have smaller and more delicate airways, making them more susceptible to damage from high suction pressures. Using lower suction pressures is essential to ensure the safety and well-being of the neonate.

Choice B rationale:

An adult with a tracheostomy tube may require higher suction pressure compared to other age groups. Adults generally have larger airways and more significant secretion production. Adequate suction pressure is necessary to effectively remove secretions and maintain airway patency.

Choice C rationale:

A child with a tracheostomy tube would typically require lower suction pressure than an adult. Children have smaller airways than adults, and using high suction pressures could cause harm and discomfort.

Choice D rationale:

An infant with a tracheostomy tube would require lower suction pressure compared to an adult. Infants have smaller airways and are more sensitive to changes in pressure. Using higher suction pressure could cause trauma to the delicate tissues in their airways.

A. Administering antibiotics. B. Increasing suction frequency. C. Providing humidification and hydration. D. Performing daily tracheostomy tube changes. E. Recommending a fenestrated tracheostomy tube.

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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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

Which of the following patients would require a higher suction pressure during tracheostomy tube suctioning?

Correct Answer is B

Explanation

A client with a tracheostomy tube is experiencing dry and crusted secretions. What intervention would the nurse provide to address this issue?

Correct Answer is C

Explanation

(Select all that apply). A nurse is gathering equipment for suctioning a tracheostomy tube. Which of the following items should the nurse include in the setup?

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?

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

A patient with a tracheostomy tube is speaking with a low risk of aspiration. What type of tracheostomy tube would be most suitable for this patient?

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?

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:

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

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