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:
The nurse should report the finding of a 6-month-old infant with a spiral fracture to a lower extremity to local authorities. Spiral fractures in infants, especially those who are not yet independently mobile, raise concerns about possible child abuse or non-accidental trauma. The unique pattern of spiral fractures is often associated with twisting forces, which are unlikely to occur accidentally in infants who cannot perform such movements. Reporting such cases is essential to ensure the safety and well-being of the child.
Choice B rationale:
A 9-month-old infant exposed to bedbugs and cellulitis is not an emergency that requires reporting to local authorities. While cellulitis can be serious, it is not an immediate threat to the child's safety, and the focus should be on providing appropriate medical care.
Choice C rationale:
A 4-year-old preschooler with rivalry among siblings does not indicate a need for reporting to local authorities. Sibling rivalry is a common occurrence in families and does not pose a threat to the child's safety. It is a social and developmental issue that can be addressed within the family.
Choice D rationale:
A 24-month-old toddler experiencing occasional incontinence does not require reporting to local authorities. Occasional incontinence can be a normal part of toddler development as they learn to control their bladder. It does not indicate abuse or immediate danger to the child.
Correct Answer is C
Explanation
Choice A rationale:
Ensuring the infant bottle feeds for 45 minutes is not recommended for an infant with heart failure. Prolonged feeding sessions can lead to increased fatigue and stress on the infant's cardiovascular system, exacerbating the heart failure symptoms.
Choice B rationale:
Administering digoxin for a pulse of 70/min is not appropriate. Digoxin is commonly used in heart failure cases to improve cardiac contractility and reduce heart rate. However, giving digoxin solely based on the heart rate without considering other factors can lead to potential overdose and adverse effects.
Choice C rationale:
(Correct Choice) Allowing for frequent rest periods is crucial in the plan of care for an infant with heart failure. Infants with heart failure often experience fatigue and difficulty feeding due to compromised cardiac function. Allowing them to rest between activities helps conserve energy and supports their overall well-being.
Choice D rationale:
Maintaining the infant in a supine position is not the best choice for an infant with heart failure. While the supine position is recommended for safe sleep to reduce the risk of sudden infant death syndrome (SIDS), it may not be optimal for an infant with heart failure. An inclined position may be more suitable to alleviate potential respiratory distress.
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