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: Restricting salt in a child with CF is not advised because these children can lose excessive amounts of salt when they sweat. Maintaining adequate salt intake is important to prevent electrolyte imbalances.
Choice B reason: Limiting fluid intake is not recommended for children with CF. Adequate hydration helps to thin mucus secretions, making them easier to clear from the lungs.
Choice C reason:This is the correct choice. Pancreatic enzyme replacement therapy is essential for children with CF because it helps them digest and absorb nutrients from their food, which is critical due to the malabsorption issues associated with CF.
Choice D reason: Preparing low-fat meals with limited protein is not recommended for children with CF. They require a high-calorie diet with sufficient protein to meet their nutritional needs due to their increased metabolic rate and malabsorption issues.
Correct Answer is D
Explanation
Choice A reason: This statement is normal, as an infant who is 2 months old should have an axillary temperature between 36.5°C and 37.5°C (97.7°F and 99.5°F). The nurse should assess the infant's temperature using an axillary or tympanic method, as oral and rectal methods are not recommended for infants.
Choice B reason: This statement is normal, as an infant who is 2 months old should have a heart rate between 100 and 160 beats per minute. The nurse should assess the infant's heart rate by auscultating the apical pulse for a full minute.
Choice C reason: This statement is normal, as an infant who is 2 months old should have a respiratory rate between 25 and 40 breaths per minute. The nurse should assess the infant's respiratory rate by observing the chest movements for a full minute.
Choice D reason: This statement is abnormal, as an infant who is 2 months old should have a weight gain of about 150 to 200 grams (5 to 7 ounces) per week. The current weight of the infant indicates a failure to thrive, as it is below the 5th percentile for the age and gender. The nurse should report this finding to the provider and assess the infant's feeding habits, growth chart, and developmental milestones.
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