A nurse is completing an assessment following suctioning of a child who has a tracheostomy. Which of the following findings should the nurse identify as an indication that the procedure has been effective?

Increased respiratory rate

Decreased oxygen saturation

Clear breath sounds

Increased oral secretions

Answer and Explanation

The Correct Answer is C

A. Increased respiratory rate: An increased respiratory rate may indicate that the child is experiencing respiratory distress or discomfort, which could be a sign that suctioning was not effective or that it was too aggressive. Ideally, after suctioning, the child's respiratory rate should stabilize or decrease as they are able to breathe more comfortably with a clear airway.

B. Decreased oxygen saturation: A decreased oxygen saturation level may indicate that the child is not receiving enough oxygen, which could be a sign of ineffective suctioning or airway obstruction. Effective suctioning should improve oxygenation by removing secretions and allowing for better airflow. A decrease in oxygen saturation would suggest the need for further assessment and intervention.

C. Clear breath sounds: This is the correct option. Clear breath sounds indicate that the airway has been effectively cleared of excess secretions, allowing for clear airflow. After suctioning, the nurse should listen for clear breath sounds without any crackles, wheezes, or other abnormal sounds indicating obstruction or congestion.

D. Increased oral secretions: Increased oral secretions may suggest that suctioning was not effective in clearing secretions from the airway, leading to pooling of secretions in the mouth. Effective suctioning should remove excess secretions from the airway, reducing the need for excessive oral secretions.

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Correct Answer is A

Explanation

A. Pull the pinna down and back: This technique is appropriate for administering otic drops to an infant or young child. By gently pulling the pinna (outer ear) down and back, it straightens the ear canal, allowing the drops to enter more effectively.

B. Insert the dropper into the ear canal: This option is incorrect. It is essential not to insert the dropper directly into the ear canal, especially in young children, to prevent injury to the ear drum or ear canal.

C. Administer the ear drops at 5.5°C (42°F): The temperature at which the ear drops are administered is not typically specified in practice. Room temperature drops are generally recommended for patient comfort, but they do not need to be at a specific temperature.

D. Massage the area behind the ear: Massaging the area behind the ear after administering otic drops can help distribute the medication within the ear canal. However, it is essential to follow specific instructions provided by the healthcare provider regarding post-administration care.

A. Iron deficiency anemia B. Vitamin A toxicity C. Impaired carbohydrate metabolism D. Lactose intolerance

Correct Answer is A

Explanation

A. Iron deficiency anemia: Whole milk is a poor source of iron, and excessive consumption of whole milk can displace iron-rich foods from the diet. Therefore, a toddler who consumes a large amount of whole milk and has a poor appetite is at risk for iron deficiency anemia due to inadequate iron intake. Iron deficiency anemia is characterized by low levels of iron in the body, leading to decreased production of red blood cells and impaired oxygen transport.

B. Vitamin A toxicity: While excessive intake of vitamin A can lead to toxicity, it is unlikely to occur from consuming whole milk alone. Vitamin A toxicity is more commonly associated with excessive intake of vitamin A supplements or foods that are rich in preformed vitamin A, such as liver. Therefore, vitamin A toxicity is not a significant risk for a toddler who drinks whole milk.

C. Impaired carbohydrate metabolism: There is no direct relationship between whole milk consumption and impaired carbohydrate metabolism. Impaired carbohydrate metabolism is typically associated with conditions such as diabetes mellitus or metabolic syndrome, rather than dietary factors like milk consumption.

D. Lactose intolerance: Lactose intolerance is the inability to digest lactose, the sugar found in milk and dairy products, due to a deficiency of the enzyme lactase. While excessive consumption of whole milk may exacerbate symptoms in a child with lactose intolerance, it is not a risk factor for developing lactose intolerance itself. Lactose intolerance is more commonly observed in individuals of certain ethnic backgrounds or those with a genetic predisposition.

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A nurse is completing an assessment following suctioning of a child who has a tracheostomy. Which of the following findings should the nurse identify as an indication that the procedure has been effective?

Nursing Test Bank

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