A charge nurse is observing a newly licensed nurse who is performing endotracheal suctioning for a preschool age child. Which of the following actions by the newly licensed nurse requires the charge nurse to intervene?
Applying suction for 20 seconds
Introducing the catheter without suction
Rotating the catheter between the thumb and forefinger while suctioning
Allowing the child to rest for 30 to 60 seconds between suctioning passes
The Correct Answer is B
A. Applying suction for 20 seconds:
Suctioning for 20 seconds is within the recommended duration for endotracheal suctioning in children. It allows adequate time for removing secretions without causing excessive trauma to the airway.
B. Introducing the catheter without suction:
This action is incorrect. When performing endotracheal suctioning, the catheter should be introduced into the endotracheal tube while applying suction. Introducing the catheter without suction may not effectively remove secretions and can lead to ineffective suctioning.
C. Rotating the catheter between the thumb and forefinger while suctioning:
Rotating the catheter between the thumb and forefinger while suctioning helps to prevent the catheter from sticking to the airway walls and facilitates the removal of secretions. This action is appropriate and helps ensure effective suctioning.
D. Allowing the child to rest for 30 to 60 seconds between suctioning passes:
Allowing the child to rest between suctioning passes helps minimize hypoxia and discomfort during the procedure. This action is appropriate and ensures that the child has adequate time to recover before the next suctioning pass.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Methylprednisolone: Methylprednisolone is a corticosteroid used for long-term management and prevention of asthma exacerbations. It has anti-inflammatory effects and is not typically used for immediate relief during an acute asthma attack.
B. Albuterol: Albuterol is a short-acting beta-agonist bronchodilator, which is the first-line medication for relieving acute bronchoconstriction during an asthma attack. It works quickly to open the airways and improve breathing.
C. Fluticasone: Fluticasone is an inhaled corticosteroid used for long-term asthma control and prevention of symptoms. It has anti-inflammatory effects but is not used for immediate relief during an acute asthma attack.
D. Beclomethasone: Beclomethasone is also an inhaled corticosteroid used for long-term asthma control and prevention of symptoms. Like fluticasone, it is not used for immediate relief during an acute asthma attack.
Correct Answer is C
Explanation
A. "Your child's diet should be high in carbohydrates & proteins with no restriction of fats."
This statement is not entirely accurate. While it's true that children with cystic fibrosis often require a diet that is higher in calories and protein to support growth and weight gain, there is typically a need to restrict fat intake. Pancreatic insufficiency, which is common in cystic fibrosis, can lead to malabsorption of fats and fat-soluble vitamins. Therefore, a dietitian may recommend enzyme replacement therapy and a diet that is moderate in fat but high in calories and protein.
B. "Limit your child's intake of sodium to avoid complications."
This statement is not accurate. Cystic fibrosis can lead to excessive loss of salt in sweat, which can contribute to dehydration and electrolyte imbalances. Therefore, limiting sodium intake can cause electrolyte disturbances.
C. "A pigeon-shaped chest might become evident as the disease progresses."
This statement is accurate. Cystic fibrosis can cause chronic lung infections and inflammation, leading to structural changes in the chest over time. One common manifestation is a barrel-shaped or "pigeon-shaped" chest, which can occur as the disease progresses. This may result from hyperinflation of the lungs due to air trapping and chronic respiratory compromise.
D. "Administer a bronchodilator to the child after chest percussion therapy."
This statement is not necessarily accurate or applicable to all cases. Bronchodilators are medications used to help relax and open the airways in conditions such as asthma or chronic obstructive pulmonary disease (COPD). While bronchodilators may be part of the treatment regimen for some individuals with cystic fibrosis, their use after chest percussion therapy would depend on the individual's specific respiratory symptoms and treatment plan. It's important for the parents to follow the healthcare provider's instructions regarding medication administration.

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