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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. Droplet:
Pertussis is primarily transmitted through respiratory droplets when an infected person coughs or sneezes. Droplet precautions involve placing the child in a private room or with another child with the same infection. Healthcare workers should wear a mask or respirator when entering the room to protect against droplet transmission.
B. Contact:
Contact precautions are used for infections that can be spread by direct or indirect contact with the patient or their environment. Pertussis is not typically spread through contact with contaminated surfaces or objects.
C. Airborne:
Airborne precautions are used for infections that are transmitted through small droplet nuclei that remain in the air for long periods. Pertussis is primarily transmitted through larger respiratory droplets rather than tiny airborne particles.
D. Protective environment:
Protective environment precautions are used for patients who have weakened immune systems, such as those undergoing bone marrow transplants. These precautions are not applicable for a child with pertussis.
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