A nurse is planning to perform tracheostomy care for a toddler. Which of the following is an appropriate action for the nurse to take?

Place the child in Trendelenburg position when performing care.

Use clean technique to change the tracheostomy tube.

Have the child flex his head when securing the ties.

Clean around the stoma with full-strength hydrogen peroxide.

Answer and Explanation

The Correct Answer is C

A. Placing the child in the Trendelenburg position is not necessary for tracheostomy care. In fact, this position is generally not recommended for routine tracheostomy care.

B. Sterile technique, not clean technique, should be used when changing the tracheostomy tube to reduce the risk of infection.

C. This is the correct action. Having the child flex his head can help prevent tension on the tracheostomy ties and ensure a secure and comfortable fit.

D. Full-strength hydrogen peroxide is too harsh and can cause irritation to the skin around the stoma. It is recommended to use normal saline or a mild soap and water solution for cleaning.

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Correct Answer is B

Explanation

A. Rotavirus vaccine is not typically indicated for adolescents. It is usually administered to infants.

B. Correct. Adolescents with sickle cell anemia are at increased risk for infections,

including those caused by Streptococcus pneumoniae. The pneumococcal conjugate vaccine (PCV) helps protect against certain types of pneumococcal bacteria.

C. The MMR vaccine provides immunity against measles, mumps, and rubella, but it is not specifically indicated for adolescents with sickle cell anemia. They should receive
this vaccine as recommended for their age group.

D. The RSV vaccine is primarily recommended for infants and young children at high risk for severe respiratory syncytial virus (RSV) infection. It is not typically indicated for adolescents with sickle cell anemia.

A. Hypertension B. Increased urine output C. Increased respiratory rate D. Capillary refill of 2 seconds

Correct Answer is C

Explanation

A. Hypertension is not a typical finding in severe dehydration. In fact, dehydration often leads to decreased blood pressure.

B. Increased urine output is not a typical finding in severe dehydration. Dehydration leads to decreased urine output as the body tries to conserve fluids.

C. This is the correct answer. In severe dehydration, the body compensates by increasing the respiratory rate to try to maintain oxygen levels and remove excess carbon dioxide. This is a compensatory mechanism in response to metabolic acidosis, which can occur with dehydration.

D. A capillary refill of 2 seconds indicates normal perfusion. In severe dehydration, capillary refill may be prolonged, indicating poor perfusion.

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A nurse is planning to perform tracheostomy care for a toddler. Which of the following is an appropriate action for the nurse to take?

Nursing Test Bank

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