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 B
Explanation
Choice A reason: This statement is incorrect, as reports of thirst are not a manifestation of hemorrhage following a tonsillectomy. Thirst may be caused by dehydration, dry mouth, or fever, which are common after surgery.
Choice B reason: This statement is correct, as frequent swallowing is a manifestation of hemorrhage following a tonsillectomy. Swallowing may indicate that the child is bleeding from the surgical site and trying to clear the blood from the throat. The nurse should inspect the child's mouth and throat for signs of bleeding and notify the provider.
Choice C reason: This statement is incorrect, as mouth breathing is not a manifestation of hemorrhage following a tonsillectomy. Mouth breathing may be due to nasal congestion, pain, or swelling, which are expected after surgery.
Choice D reason: This statement is incorrect, as reports of pain are not a manifestation of hemorrhage following a tonsillectomy. Pain is a normal and expected outcome after surgery and should be managed with analgesics and comfort measures.
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.
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