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

Explanation

Choice A rationale:

This choice is not appropriate because increased coughing, difficulty breathing, and stridor suggest a mechanical issue rather than an infection. Monitoring for fever or increased secretions is not addressing the potential cause of the symptoms.

Choice B rationale:

This choice is not appropriate for the presented situation. Expectorating secretions may not directly address the narrowed tracheal lumen due to scar formation, and it is not the primary intervention needed.

Choice C rationale:

This is the correct choice. Ensuring the tracheostomy tube is securely positioned in the midline can help prevent further narrowing of the tracheal lumen. Proper alignment and securing of the tube can optimize airflow and reduce complications related to scar formation.

Choice D rationale:

Using a larger tracheostomy tube may not be the most appropriate action in this situation. Enlarging the tube may not be necessary and could potentially cause other complications. It's better to ensure proper positioning and consider other interventions before resorting to a larger tube.

A. Proceed with the suctioning as planned. B. Report the findings to the healthcare provider. C. Clean the area with hydrogen peroxide before suctioning. D. Use an antiseptic solution to cleanse the stoma.

Correct Answer is B

Explanation

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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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 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?

Correct Answer is C

Explanation

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?

Correct Answer is B

Explanation

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

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

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

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

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

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

(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?