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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the correct instruction. Varicella (chickenpox) is highly contagious. The child should be kept away from others until all lesions are crusted over and no new lesions have formed for at least 24 hours. This typically indicates that the child is no longer contagious.
B. Applying calamine lotion can help alleviate itching and discomfort associated with the vesicles. This is a supportive measure but does not address the contagious nature of the disease.
C. Dressing the child in warm clothing is not specific to the management of varicella. It is important to keep the child comfortable, but this instruction does not address the
contagious period.
D. It is generally safe to give the child a bath during varicella. Warm baths with mild soap can help soothe itching. However, the child should be dried gently to avoid breaking open any vesicles.
Correct Answer is C
Explanation
A. Methylprednisolone is a corticosteroid that can help reduce inflammation. While it may be beneficial in some cases of allergic reactions, it is not the first-line treatment for severe
anaphylaxis. In this situation, the priority is to address the immediate symptoms and stabilize the child's condition.
B. Administering oxygen is an important intervention, especially if the child is experiencing respiratory distress. However, in the case of severe anaphylaxis, administering epinephrine is the highest priority as it addresses multiple aspects of the reaction, including airway constriction,
low blood pressure, and hives.
C. This is the correct action. Epinephrine is the first-line treatment for anaphylaxis. It works rapidly to improve breathing, increase blood pressure, and reduce allergic symptoms. It is considered the most critical intervention in this situation.
D. Nebulized bronchodilators can be beneficial for respiratory distress, but they are not the first-line treatment for severe anaphylaxis. Epinephrine is more effective in rapidly reversing the
allergic reaction and stabilizing the child's condition. It addresses a broader range of symptoms in anaphylaxis compared to a bronchodilator.
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