A nurse is planning care for an 8-month-old infant with a tracheostomy. Which of the following actions should the nurse include in the plan of care?
Use a bulb syringe to suction the nares.
Provide antibiotic therapy.
Administer intermittent suction via the tracheostomy.
Place the infant in a prone position to sleep.
The Correct Answer is C
Choice A reason: Using a bulb syringe to suction the nares is a common practice for clearing nasal passages in infants, but it is not the primary concern for an infant with a tracheostomy, which requires specific care to maintain airway patency.
Choice B reason: Providing antibiotic therapy may be necessary if there is an infection, but it is not a standard care action for a tracheostomy without evidence of infection.
Choice C reason: Administering intermittent suction via the tracheostomy is essential to clear secretions and maintain airway patency, which is the greatest risk for an infant with a tracheostomy.
Choice D reason: Placing an infant in a prone position to sleep is not recommended due to the increased risk of sudden infant death syndrome (SIDS). Infants should be placed on their backs to sleep.
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Correct Answer is A
Explanation
Choice A reason: Obtaining written consent from the client is appropriate as adolescents are entitled to confidential care for STIs. This respects the client's autonomy and privacy.
Choice B reason: Contacting the client's parents may not be necessary unless the adolescent is under the age specified by law for independent consent. It could also breach confidentiality.
Choice C reason: Postponing the testing could delay diagnosis and treatment, which is not in the best interest of the client. Immediate testing is important for health and well-being.
Choice D reason: Requesting verbal consent from the social worker is not appropriate as the consent should come directly from the client or their legal guardian, if required.
Correct Answer is A
Explanation
Choice A reason: Clearing the area of hard objects is crucial to prevent injury during a seizure. It helps to ensure that the child does not hit or get hurt by any objects in the vicinity while experiencing convulsions.
Choice B reason: Minimizing movement of the limbs is not recommended as it can cause injury to the child. Instead, the child should be allowed to move freely without restraint to avoid causing harm to their joints or muscles.
Choice C reason: Inserting a tongue blade between the teeth is an outdated and dangerous practice. It can cause injury to the child's mouth or teeth and may lead to choking if the tongue blade breaks.
Choice D reason: Placing the child in a prone position is not advised as it can obstruct the airway. The child should be placed on their side in the recovery position to keep the airway clear and allow fluids to drain from the mouth.
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