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","D"]
Explanation
A. Cranberry juice
Cranberry juice may be too acidic and could irritate the surgical site. It's best to avoid acidic beverages immediately following a tonsillectomy.
B. Ice-cream
This option is suitable. Ice-cream is cold and soothing, and it can help numb the throat, providing relief from discomfort after a tonsillectomy. However, it's essential to ensure that the ice-cream is not too cold to avoid causing discomfort.
C. Hot tea
Hot tea is not recommended immediately following a tonsillectomy. Hot liquids can irritate the surgical site and may cause discomfort. It's best to avoid hot beverages until the throat has had time to heal.
D. Italian ice
Italian ice is a frozen dessert similar to a slushy, and it can be a suitable option after a tonsillectomy. Like ice-cream, Italian ice is cold and can help numb the throat, providing relief from discomfort.
Correct Answer is A
Explanation
A. Apical:
The apical pulse is the most reliable location to assess the pulse in infants. It is located at the apex of the heart, which is typically found at the fifth intercostal space at the midclavicular line. Assessing the apical pulse allows for a direct measure of the heart rate and rhythm, which is especially important in infants to evaluate cardiac function accurately. The apical pulse is commonly assessed using a stethoscope placed at the point of maximum impulse (PMI) on the chest.
B. Dorsalis pedis:
The dorsalis pedis pulse is located on the top of the foot, typically in the region between the first and second metatarsal bones. While the dorsalis pedis pulse can be palpated in older children and adults, it may be difficult to palpate accurately in infants, especially those with smaller or more delicate feet. Therefore, it is not the preferred site for pulse assessment in infants.
C. Temporal:
The temporal pulse is located on the side of the head, just above the ear. While the temporal pulse can be palpated in some individuals, it is not typically used to assess the pulse in infants. Palpating the temporal pulse in infants may be more challenging and less reliable compared to other pulse sites, especially given the smaller size of the temporal artery in infants.
D. Carotid:
The carotid pulse is located in the neck, alongside the trachea, and can be palpated by gently pressing the fingers against the carotid artery. While the carotid pulse is easily palpable in adults and older children, it is not typically the preferred site for pulse assessment in infants. Palpating the carotid pulse in infants carries a risk of injury to the delicate structures in the neck and may not provide an accurate representation of the pulse rate.
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