A nurse is preparing to perform suctioning for an infant who has a partial mucus occlusion of her tracheostomy tube. Which of the following actions should the nurse plan to take?
Instill 2 mL of 0.9% sodium chloride prior to suctioning.
Select a catheter that fits snugly into the tracheostomy tube.
Use a clean technique when performing suctioning.
Apply suction in 3 to 4-second increments.
The Correct Answer is D
Answer: d. Apply suction in 3 to 4-second increments.
Rationale:
- a. Instill 2 mL of 0.9% sodium chloride prior to suctioning: While saline instillations may be used in some cases, it is not universally recommended for infants with tracheostomies and depends on the specific situation and healthcare provider's protocol. The priority in this case is to quickly clear the partial mucus occlusion to prevent respiratory distress.
- b. Select a catheter that fits snugly into the tracheostomy tube: This is incorrect. Selecting a catheter that fits tightly can damage the delicate tracheal mucosa and increase the risk of bleeding. A smaller-diameter catheter that allows for gentle passage is preferred.
Opens in a new window
www.researchgate.net
Tracheostomy tube and different catheter sizes
- c. Use a clean technique when performing suctioning: This is absolutely essential for all suctioning procedures to minimize the risk of infection. However, it is not the specific action that addresses the immediate concern of clearing the partial mucus occlusion.
- d. Apply suction in 3 to 4-second increments: This is the correct approach for suctioning an infant with a tracheostomy. Applying short, intermittent suction bursts minimizes the risk of hypoxia and tissue trauma while effectively removing secretions.
Therefore, the most important action for the nurse to take is to apply suction in short, 3-4 second bursts to effectively clear the mucus occlusion while minimizing risks to the infant.
Additional Points:
- The nurse should use sterile suction equipment and sterile technique throughout the procedure.
- The suction pressure should be set at the lowest effective level, typically 80-120 mmHg.
- The nurse should monitor the infant for signs of respiratory distress, such as increased work of breathing, retractions, and oxygen desaturation, before, during, and after suctioning.
- If the mucus occlusion is not cleared after several attempts, the nurse should seek assistance from a healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Stabilizing the nasogastric tube by taping it to the infant's cheek is a crucial step in preventing accidental removal or displacement of the tube during feedings. Infants are known for their active movements, which could lead to unintentional removal of the tube. Taping the tube securely helps maintain its proper placement and ensures the delivery of nutrients.
Choice B rationale:
Positioning the infant in a supine (lying on the back) position during feedings is not recommended. This position could lead to an increased risk of aspiration, where the feedings could enter the airway and lungs, causing respiratory issues. The recommended position for nasogastric tube feedings is semi-upright or upright to minimize this risk.
Choice C rationale:
Aspirating residual fluid from the infant's stomach and discarding it is not standard practice for nasogastric tube feedings. Aspirating can introduce the risk of infection or cause irritation to the stomach lining. Additionally, residual fluid can provide valuable information about the infant's digestion and absorption, and its presence should be taken into consideration when adjusting feedings.
Choice D rationale:
Microwaving the infant's formula to a temperature of 41°C (105.8°F) is not safe. Formula should be warmed gently using warm water or a bottle warmer to avoid overheating, which could burn the infant's mouth and esophagus. Microwaving can cause uneven heating and lead to hot spots within the formula, posing a risk of burns.
Correct Answer is C
Explanation
The correct answer is choice C. 6.8 to 7.7 kg (15 to 17 lb).
Choice A rationale:
This weight range is above the average for a 6-month-old infant. According to growth charts, the 50th percentile weight for a 6-month-old male is approximately 7.9 kg (17 lb 8 oz), and for a female, it’s about 7.3 kg (16 lb 1 oz). Therefore, 8.6 to 9.5 kg would be considered above average and not the anticipated weight for most infants.
Choice B rationale:
This weight range is below the average for a 6-month-old infant. The average weight at 6 months is significantly higher than 4.1 to 5 kg, as infants are expected to double their birth weight by 5 months of age. Therefore, an infant weighing between 9 to 11 lb at 6 months would be considered underweight.
Choice C rationale:
This weight range is within the average for a 6-month-old infant. As mentioned, the 50th percentile weights for 6-month-old infants are approximately 7.9 kg for males and 7.3 kg for females. This choice falls within the expected weight gain trajectory where an infant is anticipated to double their birth weight by 5 months and then gain an additional pound or so by 6 months.
Choice D rationale:
This weight range is significantly above the average for a 6-month-old infant. It is well above the 95th percentile for this age group and would be considered unusual without underlying health conditions that could contribute to such a weight at this age. An infant weighing between 23 to 25 lb at 6 months would be exceptionally rare and likely indicative of an abnormal growth pattern.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today