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 A
Explanation
Choice A reason: The child has signs of dehydration and hypovolemic shock, such as vomiting, melena, abdominal pain, and weak pedal pulses. Dehydration is a loss of fluid and electrolytes from the body, which can result from gastroenteritis. Hypovolemic shock is a life-threatening condition that occurs when the blood volume is too low to maintain adequate perfusion and oxygen delivery to the vital organs.
Choice B reason: The child does not have signs of peritonitis and septic shock, such as fever, chills, rigors, tachycardia, hypotension, and abdominal rigidity. Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity and organs. Septic shock is a severe infection that causes systemic inflammatory response syndrome and organ dysfunction.
Choice C reason: The child does not have signs of pancreatitis and cardiogenic shock, such as elevated serum amylase and lipase, jaundice, dyspnea, crackles, and chest pain. Pancreatitis is an inflammation of the pancreas, an organ that produces digestive enzymes and hormones. Cardiogenic shock is a failure of the heart to pump enough blood to meet the body's needs.
Choice D reason: The child does not have signs of peptic ulcer and anaphylactic shock, such as hematemesis, dyspepsia, urticaria, angioedema, and wheezes. Peptic ulcer is a sore in the lining of the stomach or duodenum, caused by factors such as Helicobacter pylori infection, NSAIDs, or stress. Anaphylactic shock is a severe allergic reaction that causes bronchoconstriction, vasodilation, and hypotension.
Correct Answer is D
Explanation
Choice A reason: Half-strength infant formula is not a clear liquid and should not be given to an infant with intussusception. Infant formula contains proteins, fats, and carbohydrates that can increase the risk of bowel obstruction, infection, and perforation.
Choice B reason: Half-strength orange juice is not a clear liquid and should not be given to an infant with intussusception. Orange juice contains fructose, citric acid, and potassium that can irritate the bowel, cause osmotic diarrhea, and worsen dehydration.
Choice C reason: Sterile water is a clear liquid, but it is not the best choice for an infant with intussusception. Sterile water does not contain any electrolytes or glucose and can dilute the blood sodium level, leading to hyponatremia and seizures.
Choice D reason: Oral electrolyte solution is the best fluid for an infant with intussusception, as it contains the optimal balance of electrolytes and glucose to prevent dehydration and restore fluid balance. Oral electrolyte solution is recommended by the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) for the management of dehydration in children.
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