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 B
Explanation
The correct answer is choiceb. Perceives death as a punishment.
Choice A rationale:
Preschool-aged children generally do not understand that death is permanent.They often view death as temporary or reversible, similar to what they see in cartoons.
Choice B rationale:
Preschoolers may perceive death as a punishment for something they did or thought.This age group often feels guilt and shame, believing their actions or thoughts caused the illness or death.
Choice C rationale:
Worrying about physical body changes is more typical in older children who have a better understanding of the physical aspects of illness and death.
Choice D rationale:
Feelings of isolation are more common in older children and adolescents who are more aware of social dynamics and the implications of their illness.
Correct Answer is C
Explanation
Choice A rationale:
Placing the infant in a supine position during naps might not be the best action for an infant with heart failure. In heart failure, infants often experience difficulty breathing due to fluid accumulation in the lungs. Placing the infant in a more upright position, such as semi-Fowler's, can help alleviate some of this respiratory distress.
Choice B rationale:
Feeding the infant a bottle every 4 hours is important, but it might not directly address the immediate concerns of an infant with heart failure. Infants with heart failure might have difficulty feeding due to fatigue and respiratory distress. Feeding smaller, more frequent meals and assessing the infant's feeding tolerance is crucial.
Choice C rationale:
Correct Answer. Documenting the infant's respiratory rate every 2 hours is an important action. Infants with heart failure often have respiratory distress and an increased respiratory rate, as the body tries to compensate for decreased cardiac output. Documenting the respiratory rate will help the healthcare team monitor the infant's condition and assess the effectiveness of interventions.
Choice D rationale:
Withholding digoxin if the infant's heart rate is greater than 100/min is not necessarily the correct action. Digoxin is a medication commonly used in heart failure to improve cardiac contractility. While it's important to monitor the infant's heart rate, a heart rate of greater than 100/min might be due to the body's compensatory mechanisms in response to heart failure. Withholding the medication without consulting a healthcare provider might not be appropriate.
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