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: Applying and releasing elbow restraints every hour prevents the infant from touching or injuring the surgical site, while allowing some movement and circulation. This is a standard nursing intervention for infants who have undergone cleft palate repair.
Choice B reason: Keeping the infant supine is not recommended, as it increases the risk of aspiration and bleeding. The infant should be placed in a side-lying or upright position to facilitate drainage and prevent pressure on the suture line.
Choice C reason: Feeding the infant with a spoon for 48 hours is not necessary, as it may cause discomfort and trauma to the palate. The infant can be fed with a special nipple or a syringe with a rubber tip that delivers small amounts of formula or breast milk to the side of the mouth.
Choice D reason: Suctioning the mouth with an oral suction tube is contraindicated, as it may damage the palate and cause bleeding or infection. The nurse should use a bulb syringe to gently suction the nose and mouth if needed.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect, as montelukast is a leukotriene receptor antagonist that is used for long-term control and prevention of asthma symptoms. It is not effective for acute asthma attacks, as it does not provide immediate bronchodilation.
Choice B reason: This statement is incorrect, as budesonide is an inhaled corticosteroid that is used for long-term control and prevention of inflammation in asthma. It is not effective for acute asthma attacks, as it does not provide immediate relief of bronchospasm.
Choice C reason: This statement is incorrect, as prednisone is an oral corticosteroid that is used for short-term treatment of severe asthma exacerbations. It is not effective for acute asthma attacks, as it takes several hours to exert its anti-inflammatory effect.
Choice D reason: This statement is correct, as albuterol is a short-acting beta2 agonist that is used for quick relief of acute asthma symptoms. It provides rapid bronchodilation by relaxing the smooth muscles of the airways.
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