Which statement is most important for the nurse to make when caring for an anxious patient with a new tracheostomy?

"I have cared for patients who were able to have the tracheostomy reversed."

“I understand that you might be apprehensive."

“I will be efficient and give care quickly."

"I will wait until your tracheostomy heals before teaching."

Answer and Explanation

The Correct Answer is B

A. "I have cared for patients who were able to have the tracheostomy reversed. While this may offer hope, it shifts the focus to long-term outcomes rather than addressing the patient's current emotional state. Not all tracheostomies are reversible, and offering this reassurance prematurely may set unrealistic expectations.

B. “I understand that you might be apprehensive." This statement acknowledges the patient's anxiety and fosters trust. Demonstrating empathy helps reduce emotional distress, encourages open communication, and supports emotional adaptation to the tracheostomy.

C. “I will be efficient and give care quickly." Although efficiency is important, this response may come off as dismissive of the patient's emotional needs. It prioritizes task completion over patient-centered care and fails to address the underlying anxiety.

D. "I will wait until your tracheostomy heals before teaching." Teaching should begin early, even in small steps, to help the patient gradually understand and adapt to tracheostomy care. Delaying education may increase fear, uncertainty, and dependence on others for care.

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Correct Answer is A

Explanation

A. Assess the posterior pharynx for active bleeding:Frequent throat clearing without reported pain after a tonsillectomy may indicate active bleeding, which can be life-threatening. Silent bleeding may drip down the throat and trigger subtle clearing rather than coughing or spitting, making visual inspection an immediate priority.

B. Place the client in the side lying position:Side-lying can help prevent aspiration if bleeding occurs, but it does not replace the need to directly assess for bleeding first. Positioning should follow an initial airway and bleeding assessment.

C. Give the client juice through a straw:Using a straw is discouraged after tonsillectomy because the suction motion can disrupt clots and provoke bleeding. Juice may be appropriate for hydration, but not with a straw and not before checking for bleeding.

D. Offer the client ice cream to coat the throat:Cold soft foods like ice cream may soothe the throat and reduce swelling, but this should not be the first action when silent bleeding is suspected. The priority is ensuring that no active bleeding is occurring before offering food.

A. Placing infants on their backs or sides for sleep B. Positioning the infant prone for sleep C. Wrapping the infant snugly for rest periods D. Sitting the infant up in an infant seat

Correct Answer is A

Explanation

A. Placing infants on their backs or sides for sleep:The "Back to Sleep" campaign recommends placing infants on their backs for all sleep times to significantly reduce the risk of SIDS. Back sleeping it keeps the airway more open and reduces the chance of suffocation.

B. Positioning the infant prone for sleep:Placing an infant on their stomach increases the risk of SIDS due to potential airway obstruction and rebreathing of exhaled carbon dioxide. This position is strongly discouraged by pediatric guidelines for safe sleep.

C. Wrapping the infant snugly for rest periods:Swaddling can be safe if done correctly, but wrapping too tightly, especially around the chest or hips, and using loose blankets can increase the risk of overheating or suffocation.

D. Sitting the infant up in an infant seat:Keeping an infant in a sitting position for sleep, such as in a car seat or infant carrier, increases the risk of airway obstruction and is not recommended for routine sleep. Infants should sleep on a flat, firm surface to reduce the risk of SIDS.

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Which statement is most important for the nurse to make when caring for an anxious patient with a new tracheostomy?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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