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 A reason: Soaking hairbrushes in boiling water is a good practice for decontamination, but it is not specific to the treatment of impetigo, which is a bacterial skin infection.
Choice B reason: Acyclovir is an antiviral medication and would not be effective against impetigo, which is caused by bacteria, typically Staphylococcus aureus or Streptococcus pyogenes.
Choice C reason: Sealing soft toys in a plastic bag for 14 days may help to prevent the spread of infection, but it is not a direct treatment for impetigo itself.
Choice D reason: Applying a bactericidal ointment, such as mupirocin, is a standard treatment for impetigo. It helps to eliminate the bacteria causing the infection and promotes healing of the skin lesions.
Correct Answer is B
Explanation
Choice A reason: Teaching the child about cast care is important, but it is not the first action to take. Education on cast maintenance and activity restrictions will follow after addressing immediate needs.
Choice B reason: Administering pain medication should be the first action taken by the nurse. After a cast application for a fracture, the child is likely experiencing pain, and managing this pain is a priority to ensure comfort and facilitate healing.
Choice C reason: Elevating the child's leg is a subsequent action that can help reduce swelling and discomfort, but it is not the first action to take. Pain management is the priority before positioning.
Choice D reason: Petaling the edges of the cast, which involves placing soft material around the rough edges to prevent skin irritation, is important but not the first action. The initial focus should be on pain relief.
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