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. Increased restlessness can indicate hypoxia, pain, or worsening shock, which are critical concerns in a toddler with significant burns. This finding should be reported immediately.
B. Respiratory rate of 25/min is within the normal range for a toddler (22-37 breaths per minute) and does not require immediate intervention.
C. Bowel sounds of 20/min are normal and do not indicate a complication.
D. Urinary output of 35 mL/hr is adequate for a toddler (goal: ≥1-2 mL/kg/hr, which would be ≥20-40 mL/hr for a 20 kg child) and does not require reporting.
Correct Answer is C
Explanation
A. There is no need to seal soft toys in a plastic bag for 14 days as impetigo is not typically spread through inanimate objects. However, it is important to discourage the child from scratching the lesions to prevent further spread.
B. Soaking hairbrushes in boiling water is not necessary for the management of impetigo.
Impetigo is caused by bacteria, not lice, so boiling hairbrushes is not a standard recommendation for this condition.
C. This is the correct instruction. Applying a bactericidal ointment (e.g., mupirocin) to the impetigo lesions is a common treatment approach. This helps to eliminate the bacteria causing the infection and promote healing.
D. Administering acyclovir is not indicated for impetigo. Acyclovir is an antiviral
medication used to treat viral infections, such as herpes simplex virus. Impetigo is caused by bacterial infection, not a virus.
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