A nurse is reinforcing teaching with a newly licensed nurse about tracheostomy care for a toddler. Which of the following instructions should the nurse include in the teaching?
Secure the tracheostomy ties so that fingers cannot fit between the ties and the neck.
Suction for 20 seconds.
Clean secretions from the tube using hydrogen peroxide.
Set the vacuum pressure at 120 mmHg for suctioning.
The Correct Answer is D
A) Secure the tracheostomy ties so that fingers cannot fit between the ties and the neck. The ties should be secure but loose enough to fit one finger between the ties and the neck to prevent skin breakdown and maintain comfort.
B) Suction for 20 seconds. Suctioning for 20 seconds is too long and may cause hypoxia. Suction should not exceed 5 to 10 seconds.
C) Clean secretions from the tube using hydrogen peroxide. Hydrogen peroxide can irritate the delicate tissues and is not recommended. Saline or prescribed cleaning agents are preferred.
D) Set the vacuum pressure at 120 mmHg for suctioning. For a toddler, suction pressure should typically be between 80 and 120 mmHg to prevent mucosal damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Loop the tubing of the chest tube on the client's bed: Looping can create kinks or blockages, impeding drainage and increasing the risk of complications.
B. Place the chest tube drainage system above the level of the client's heart: This would prevent gravity drainage, leading to fluid accumulation in the pleural space.
C. Strip the client's chest tube every 2 hrs: Stripping can create high negative pressure, damaging lung tissue.
D. Tape the connections on the client's chest tube: Securing all connections with tape helps maintain a closed system and prevents air leaks.
Correct Answer is C
Explanation
A. Assist the guest to the floor and begin mouth-to-mouth resuscitation: The airway is still obstructed, and rescue breathing is not effective until the obstruction is cleared.
B. Slap the guest on the back several times: Back slaps are not recommended for adults with complete airway obstruction as they may worsen the blockage.
C. Perform the Heimlich maneuver on the guest: Grasping the throat and inability to talk indicate a complete airway obstruction, requiring immediate abdominal thrusts (Heimlich maneuver) to clear the airway.
D. Observe the guest before taking further action: Delaying intervention in the presence of complete obstruction can lead to respiratory arrest. Immediate action is required.
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