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?

Choice A reason: Withholding fluids until the client demonstrates a gag reflex is a preventive measure to avoid aspiration of liquids into the lungs. The gag reflex is a protective mechanism that prevents foreign objects from entering the airway. It can be impaired by anesthesia, surgery, or trauma. Therefore, the nurse should assess the client's gag reflex before offering fluids or food¹.

Choice B reason: Suctioning the nasopharynx as needed is another preventive measure to avoid aspiration of blood or secretions into the lungs. The nurse should monitor the client for signs of bleeding, such as frequent swallowing, restlessness, or bright red drainage. The nurse should also avoid stimulating the throat with tongue blades, straws, or suction catheters, as this can cause bleeding or spasm¹.

Choice C reason: Placing a bedside humidifier at the head of the client's bed is not a preventive measure to avoid aspiration, but rather a comfort measure to soothe the throat and reduce inflammation. Humidified air can help moisten the mucous membranes and promote healing. However, it does not prevent fluids or solids from entering the airway².

Choice D reason: Performing chest physiotherapy is not a preventive measure to avoid aspiration, but rather a treatment measure for clients who have respiratory complications, such as atelectasis or pneumonia. Chest physiotherapy involves percussion, vibration, and postural drainage to mobilize and remove secretions from the lungs. It is not indicated for clients who are postoperative following a tonsillectomy, as it can increase the risk of bleeding or pain³.

Choice E reason: Administering an antiemetic drug if the client is nauseous is a preventive measure to avoid aspiration of vomitus into the lungs. Nausea and vomiting are common postoperative complications that can be caused by anesthesia, pain, or opioids. The nurse should assess the client's nausea level and administer antiemetic drugs as prescribed. The nurse should also position the client on the side or with the head elevated to prevent aspiration¹.

Choice A reason: Red currant jelly stools are typically associated with intussusception, not pyloric stenosis. In pyloric stenosis, the stool would not have this appearance.

Choice B reason: Distended neck veins are not a clinical manifestation of pyloric stenosis. They are more commonly associated with cardiac or respiratory issues.

Choice C reason: Projectile vomiting is a classic symptom of pyloric stenosis. It occurs due to the obstruction at the pylorus, which prevents stomach contents from passing into the small intestine.

Choice D reason: A bulged abdomen is not specific to pyloric stenosis. While the abdomen may appear full, 'bulged' is not the precise term used to describe the manifestation in pyloric stenosis.