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 D
Explanation
Choice A rationale:
Hematocrit 36%. A hematocrit level of 36% falls within the normal range for adolescents. Hematocrit measures the proportion of blood volume occupied by red blood cells and is used to assess for anemia or polycythemia. A level of 36% is not a cause for concern in this case.
Choice B rationale:
Hemoglobin 12 g/dL. A hemoglobin level of 12 g/dL is within the normal range for adolescents. Hemoglobin is a protein in red blood cells that carries oxygen. This level indicates that the adolescent is not significantly anemic.
Choice C rationale:
Glucose 120 mg/dL. A glucose level of 120 mg/dL is within the normal range for a random blood glucose test. However, in the context of diabetes mellitus, the nurse should be more concerned about the HbA1c level, which reflects the average blood glucose level over the past few months.
Choice D rationale:
HbA1c 10.7%. HbA1c, or glycated hemoglobin, reflects the average blood glucose concentration over a span of approximately 2 to 3 months. An HbA1c level of 10.7% is significantly elevated and indicates poor long-term glucose control. This value suggests that the adolescent's diabetes management has not been effective, which can lead to an increased risk of diabetes-related complications over time. The nurse should notify the healthcare provider so that appropriate adjustments can be made to the treatment plan.
Correct Answer is C
Explanation
Choice A rationale:
Washing the child's pillow in cold water twice monthly is not a relevant instruction for controlling allergens in asthma management. Asthma triggers are often related to airborne allergens such as dust mites, pollen, and pet dander, and focusing on pillow washing alone does not address the broader issue of allergen exposure.
Choice B rationale:
Using a humidifier in the child's bedroom can actually worsen asthma symptoms. Humidifiers can increase the humidity in the air, promoting the growth of mold and dust mites, which are common allergens that can trigger asthma symptoms. Therefore, this instruction is not appropriate for asthma management.
Choice C rationale:
This is the correct answer. Using a damp cloth to dust the child's furniture weekly is a relevant instruction for controlling allergens. Dusting with a damp cloth helps to capture and remove allergens such as dust mites, pollen, and pet dander from surfaces, reducing the child's exposure to these triggers and potentially minimizing asthma symptoms.
Choice D rationale:
Installing carpet in the child's bedroom is not recommended for asthma management. Carpets can harbor dust mites, mold, and other allergens that can exacerbate asthma symptoms. Hard flooring surfaces that can be easily cleaned and do not trap allergens are a better choice for individuals with asthma.
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