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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: This statement is correct, as excessive movement can interfere with the accuracy of the pulse oximeter. The parents should ensure that the infant is calm and still when measuring the oxygen saturation.

Choice B reason: A pulse oximeter reading of 100% is not necessarily a cause for concern. In healthy individuals, a saturation level of 100% is achievable and does not require immediate notification to the doctor. It means that the infant's hemoglobin is fully saturated with oxygen, which is the goal of oxygen therapy. However, if you notice any issues or if the pulse oximeter consistently reads 100%, it would be a good idea to notify a healthcare professional.

Choice C reason: The probe placement does not need to be rotated every 24 hours. Once the probe is correctly positioned (usually on a finger or toe), it can remain in place for continuous monitoring without needing frequent adjustments.

Choice D reason: This statement is correct, as the probe of the pulse oximeter can be applied to a finger or a toe, depending on the size and fit of the probe. The parents should make sure that the probe is not too tight or loose, and that it does not interfere with the circulation of the extremity.

A. "We will restrict the amount of salt in our child's food." B. "I'll limit my child's fluid intake." C. "We will give our child pancreatic enzymes with snacks and meals." D. "We'll prepare low-fat meals with limited protein for my child."

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.

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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?

Nursing Test Bank

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