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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Related Questions
Correct Answer is C
Explanation
A. Minimizing movement of the limbs is not a recommended action during a seizure. It is important to allow the seizure to run its course while ensuring the safety of the child.
B. Placing the child in a prone position is not recommended during a seizure. The child should be placed in a lateral (side-lying) position to help prevent aspiration and maintain an open airway.
C. This is the correct action. Clearing the area of hard objects helps prevent injury to the child during the seizure. It is important to create a safe environment.
D. Inserting a tongue blade between the teeth is not recommended. This action can cause injury to the child's mouth or teeth. It is a myth that individuals can swallow their tongue during a seizure.
Correct Answer is B
Explanation
A. An upper respiratory infection 2 days ago is not a contraindication for the MMR vaccine. The vaccine can be administered once the child has recovered from the acute illness.
B. Correct. An allergy to neomycin, which is an antibiotic, is a contraindication for
receiving the MMR vaccine. Neomycin is present in trace amounts in the MMR vaccine, and individuals with a severe allergy to this antibiotic should not receive the vaccine.
C. A temperature of 37.2° C (99° F) is a low-grade fever and is not a contraindication for the MMR vaccine. Mild illness without fever is not a contraindication.
D. A family history of seizures is not a contraindication for the MMR vaccine. The vaccine can be safely administered to children with a family history of seizures.
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