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 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.

A. Barking cough B. Decreased stridor C. Decreased temperature D. Improved hydration

Correct Answer is B

Explanation

Choice A reason: Barking cough is not a finding that indicates the effectiveness of the treatment. Barking cough is a sign of inflammation of the larynx and trachea, which causes a hoarse and harsh sound. It is a common symptom of acute laryngotracheobronchitis, also known as croup.

Choice B reason: Decreased stridor is a finding that indicates the effectiveness of the treatment. Stridor is a high-pitched, wheezing sound that occurs when the airway is narrowed or obstructed. It is a sign of respiratory distress and hypoxia. The cool mist tent helps to humidify and soothe the airway, reducing the swelling and inflammation.

Choice C reason: Decreased temperature is not a finding that indicates the effectiveness of the treatment. Decreased temperature could be a sign of hypothermia or sepsis, which are serious complications that require immediate attention. The normal temperature range for a toddler is 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice D reason: Improved hydration is not a finding that indicates the effectiveness of the treatment. Improved hydration is a sign of adequate fluid intake and output, which are important for maintaining electrolyte balance and preventing dehydration. However, hydration status does not directly affect the airway inflammation or obstruction.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is B

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