(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?

Sterile gloves.

Sterile water or saline.

Pulse oximeter.

Sphygmomanometer.

Answer and Explanation

Correct Answer : B,E

Choice A rationale:

Sterile gloves are essential for aseptic technique during tracheostomy suctioning to prevent the introduction of infection. However, they are not included in the setup, as they are worn by the nurse performing the procedure.

Choice B rationale:

Sterile water or saline is necessary for suctioning to moisten the suction catheter and facilitate the removal of secretions without causing trauma to the airway. Therefore, it should be included in the setup.

Choice C rationale:

A pulse oximeter is used to monitor the patient's oxygen saturation and is not directly related to tracheostomy suctioning. While continuous monitoring of oxygen saturation is essential during and after the procedure, it is not a part of the setup.

Choice D rationale:

A sphygmomanometer is used to measure blood pressure and is unrelated to tracheostomy suctioning. It is not required for this procedure.

Choice E rationale:

A non-sterile towel is used to protect the patient's clothing and bed linens from any secretions or spills during the suctioning procedure. It should be included in the setup to maintain cleanliness and prevent contamination.

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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.

A. "Don't worry, this won't take long.". B. "I understand, but we need to do this to clear your airway.". C. "You're going to be just fine, trust me.". D. "Let's skip this procedure for now, and we'll try later.".

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.

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(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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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 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

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

Which statement by the nurse regarding tracheostomy care is correct?

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

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

(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?