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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Related Questions
Correct Answer is D
Explanation
Choice Areason: An upper respiratory infection 2 days ago, if the child is currently well, is not a contraindication for the MMR vaccine. Vaccines can be given to children with a minor illness.
Choice Breason: A temperature of 37.2° C (99°F) is a mild elevation and is not a contraindication for receiving the MMR vaccine. Vaccination can proceed if the child is only mildly ill.
Choice C reason: A family history of seizures is not a contraindication for the MMR vaccine. While there is a small risk of febrile seizures, the benefits of vaccination outweigh the risks.
Choice D reason: An allergy to neomycin is a contraindication for the MMR vaccine because neomycin is used in the vaccine production process. Children with a known severe allergic reaction to neomycin should not receive the vaccine.
Correct Answer is B
Explanation
Choice A reason: Preparing to administer a potassium IV bolus is not typically indicated in sickle cell crisis unless there is a documented potassium deficiency. Potassium levels must be carefully monitored to avoid hyperkalemia.
Choice B reason: Providing hydration both orally and intravenously is crucial in managing sickle cell crisis. Hydration helps to reduce blood viscosity and improve circulation, which can alleviate the pain and prevent further sickling of red blood cells.
Choice C reason: Requesting a prescription for meperidine is not recommended for pain management in sickle cell crisis due to the risk of seizures and other side effects. Other pain medications, such as morphine, are preferred.
Choice D reason: Administering multiple units of platelets is not a standard treatment for sickle cell crisis. Platelet transfusion is typically reserved for patients with thrombocytopenia or active bleeding, not for sickle cell crisis.
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