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.
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. The first dose of the Hepatitis B vaccine is typically administered shortly after birth, not at 12 months of age.
B. Correct. The first dose of the Varicella (chickenpox) vaccine is recommended at 12 months of age.
C. The Human Papillomavirus (HPV) vaccine is not typically started until the preadolescent or adolescent years, typically around ages 11-12.
D. The first dose of the Inactivated Polio Virus (IPV) vaccine is usually given at 2 months of age, with additional doses at 4 months and 6-18 months.
Correct Answer is A
Explanation
A. This statement demonstrates understanding. Elevating the broken arm on pillows can help reduce swelling and promote comfort during the night.
B. Limiting the use of the fingers of the broken arm is important for proper healing.
However, the client should still engage in gentle range-of-motion exercises as instructed by the healthcare provider.
C. Expecting some degree of swelling in the fingers is normal after the application of a cast. This statement shows understanding.
D. Sprinkling baby powder into the cast if the arm itches is not recommended. It can cause irritation and is not an effective way to address itching under the cast. The client should be instructed not to insert anything into the cast.
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