What is an important nursing consideration when suctioning a young child who has had heart surgery?
Expect symptoms of respiratory distress when suctioning.
Administer supplemental oxygen before and after suctioning.
Perform suctioning at least every hour.
Suction for no longer than 30 seconds at a time.
The Correct Answer is B
The correct answer is choice B. Administer supplemental oxygen before and after suctioning.
Choice A rationale:
Expect symptoms of respiratory distress when suctioning. While respiratory distress can occur during and after suctioning, it is not the main nursing consideration. The primary goal is to minimize any potential complications and ensure the child's safety during the procedure, which can be achieved by following appropriate guidelines.
Choice B rationale:
Administer supplemental oxygen before and after suctioning. Correct Answer. Administering supplemental oxygen before and after suctioning is crucial to maintain adequate oxygenation during and after the procedure. Suctioning can temporarily decrease oxygen levels and cause desaturation, especially in a child who has undergone heart surgery. Providing supplemental oxygen helps prevent hypoxia and supports respiratory function.
Choice C rationale:
Perform suctioning at least every hour. Frequent suctioning at least every hour is not a standard nursing practice, especially for a child who has had heart surgery. Suctioning should only be performed as needed based on the child's clinical condition, and excessive suctioning can irritate the airway and lead to complications.
Choice D rationale:
Suction for no longer than 30 seconds at a time. While limiting the duration of suctioning is important to prevent hypoxia and trauma to the airway, the specific duration of 30 seconds is not a universal rule. Suctioning should be performed for the shortest effective duration to minimize the risk of complications, but the optimal time can vary based on the child's condition and the type of suctioning being used.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Infection or inflammation close to the site.
Choice A rationale:
Tender, enlarged, and warm lymph nodes are indicative of infection or inflammation in the nearby area. Lymph nodes are part of the immune system and can become enlarged and tender when fighting off infections in their drainage area.
Choice B rationale:
While cancer can cause lymph node enlargement, it is less likely in children, and the question doesn't provide any other context to suggest cancer as the primary explanation.
Choice C rationale:
Local scalp infection might cause enlargement of the lymph nodes in the neck, but it would not be the best explanation for tender, enlarged, and warm cervical lymph nodes. Infections or inflammation close to the site of lymph node involvement are more likely.
Choice D rationale:
Infection or inflammation distal to the site wouldn't directly explain the tenderness, warmth, and enlargement of the cervical lymph nodes. Lymph nodes generally react to infections or inflammation in their drainage area.
Correct Answer is B
Explanation
The correct answer is choice B. Reduce gastric acid production.
Choice A rationale:
Preventing reflux is not the primary purpose of prescribing a histamine receptor antagonist. Histamine receptor antagonists work by reducing gastric acid production, which in turn can help alleviate symptoms of gastroesophageal reflux disease (GERD). They do not directly prevent the physical reflux of stomach contents into the esophagus.
Choice B rationale:
The primary purpose of prescribing a histamine receptor antagonist for an infant diagnosed with gastroesophageal reflux is to reduce gastric acid production. Histamine stimulates acid secretion in the stomach, and these medications (e.g., ranitidine, famotidine) block histamine receptors on stomach cells, leading to decreased acid secretion. This helps reduce the acidity of stomach contents that could contribute to esophageal irritation in GERD.
Choice C rationale:
Preventing hematemesis (vomiting blood) is not a primary action of histamine receptor antagonists. While reducing gastric acid production might indirectly help prevent complications such as bleeding due to irritation and inflammation of the esophagus, it's not the main purpose of these medications.
Choice D rationale:
Increasing gastric acid production is the opposite of the intended effect of histamine receptor antagonists. These medications are specifically used to decrease gastric acid production and provide relief from conditions where excess acid is causing problems, such as GERD.
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