A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, which of the following findings should the nurse use to determine that the procedure was effective?
Decreased respiratory rate
Stable oxygen saturation
Clear breath sounds
Pink capillary refill
The Correct Answer is C
Choice A reason: Decreased respiratory rate is not a finding that indicates the effectiveness of suctioning the tracheostomy. A decreased respiratory rate could be a sign of respiratory depression, fatigue, or hypoxia.
Choice B reason: Stable oxygen saturation is not a finding that indicates the effectiveness of suctioning the tracheostomy. A stable oxygen saturation could be maintained even if the tracheostomy is obstructed or infected.
Choice C reason: Clear breath sounds is a finding that indicates the effectiveness of suctioning the tracheostomy. Clear breath sounds mean that the airway is patent and free of secretions, mucus, or blood.
Choice D reason: Pink capillary refill is not a finding that indicates the effectiveness of suctioning the tracheostomy. Pink capillary refill is a sign of adequate perfusion and circulation, but it does not reflect the status of the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Decreased respiratory rate is not a finding that indicates the effectiveness of suctioning the tracheostomy. A decreased respiratory rate could be a sign of respiratory depression, fatigue, or hypoxia.
Choice B reason: Stable oxygen saturation is not a finding that indicates the effectiveness of suctioning the tracheostomy. A stable oxygen saturation could be maintained even if the tracheostomy is obstructed or infected.
Choice C reason: Clear breath sounds is a finding that indicates the effectiveness of suctioning the tracheostomy. Clear breath sounds mean that the airway is patent and free of secretions, mucus, or blood.
Choice D reason: Pink capillary refill is not a finding that indicates the effectiveness of suctioning the tracheostomy. Pink capillary refill is a sign of adequate perfusion and circulation, but it does not reflect the status of the airway.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as the child should take the enzymes before or with meals, not after. Taking the enzymes after meals may reduce their effectiveness and cause malabsorption of nutrients.
Choice B reason: This statement is incorrect, as the child should take the enzymes within 30 minutes before meals, not 2 hours. Taking the enzymes too early may cause them to be inactivated by the stomach acid and lose their function.
Choice C reason: This statement is incorrect, as the child does not take the enzymes to improve her metabolism, but to replace the deficient pancreatic enzymes that are needed for digestion. The child has cystic fibrosis, a genetic disorder that affects the exocrine glands and causes thick mucus to block the ducts of the pancreas.
Choice D reason: This statement is correct, as the child takes the enzymes to help digest the fat in foods, as well as other nutrients such as protein and carbohydrates. The enzymes contain lipase, amylase, and protease, which break down fat, starch, and protein respectively.
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