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.
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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:
A positive leukocyte esterase test indicates the presence of white blood cells (leukocytes) in the urine, which can be an indicator of a urinary tract infection (UTI). White blood cells are part of the body's immune response and their presence in the urine suggests inflammation and infection in the urinary tract.
Choice B rationale:
Deep gold-colored urine is not typically associated with a urinary tract infection. Normally, urine color can vary based on hydration, diet, and other factors, but color alone is not a reliable indicator of a UTI.
Choice C rationale:
The osmolality of 700 mOsm/L is not a specific finding related to urinary tract infections. Osmolality measures the concentration of particles in the urine and can vary based on hydration status. While it might be elevated in a concentrated urine sample, it is not a direct indicator of a UTI.
Choice D rationale:
A specific gravity of 1.015 is within the normal range and does not necessarily indicate a urinary tract infection. Specific gravity measures the concentration of solutes in the urine and can be influenced by hydration levels and kidney function. A UTI would primarily be indicated by the presence of white blood cells and other signs of infection in the urine.
Correct Answer is C
Explanation
Choice A rationale:
A 2 cm scalp laceration, while a concern, is not the nurse's priority in this scenario. The child's head injury could potentially be serious, but priority should be given to neurological assessments and signs of increased intracranial pressure.
Choice B rationale:
Nasal discharge negative for glucose is not indicative of a major issue in this context. While cerebrospinal fluid (CSF) leaking from the nose after head trauma is a concern, it is not mentioned in this scenario, and this choice does not take precedence over other neurological signs.
Choice C rationale:
This is the correct answer. Asymmetric pupils can be a sign of a serious neurological issue, such as a brain injury or increased intracranial pressure. It requires immediate attention and further evaluation to assess the child's neurological status and determine the extent of the injury.
Choice D rationale:
A negative Babinski reflex is a normal finding in this context and does not require immediate priority attention. The Babinski reflex is typically present in infants and disappears as the child grows older. Its absence is expected in older children and adults.
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