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. The cuff bladder covers 50% to 66% of the length of the upper arm.
Choice A rationale:
Selecting a blood pressure cuff with a bladder that covers 50% to 66% of the length of the upper arm is the appropriate criterion for determining the cuff size for a 2-year-old boy. This range ensures accurate blood pressure measurement by ensuring a proper fit on the arm. If the cuff bladder is too small or too large, it can result in inaccurate readings.
Choice B rationale:
The label "toddler" on the cuff might be helpful in identifying the intended age group, but it doesn't provide precise measurements for cuff sizing. Relying solely on a label might not account for variations in arm sizes within the toddler age group.
Choice C rationale:
The cuff bladder width being 40% of the circumference of the upper arm might not be as accurate as the length-based criterion. A cuff that fits the arm's length is more critical in ensuring proper inflation and accurate blood pressure measurement.
Choice D rationale:
The cuff bladder length covering 80% to 100% of the circumference of the upper arm might result in an excessively large cuff for a 2-year-old, which can lead to inaccurate readings. Length-based sizing is more appropriate for accuracy in this scenario.
Correct Answer is A
Explanation
Choice A rationale:
A goiter refers to the enlargement or hypertrophy of the thyroid gland. This can occur due to various reasons, such as iodine deficiency, autoimmune disorders like Hashimoto's thyroiditis, or Graves' disease (which is associated with hyperthyroidism). The thyroid gland produces hormones that regulate metabolism and growth, and when it becomes enlarged, it can lead to visible swelling in the neck.
Choice B rationale:
The posterior pituitary gland is responsible for the release of hormones like vasopressin (antidiuretic hormone) and oxytocin. A goiter is not associated with the posterior pituitary gland. Issues with the posterior pituitary can lead to problems with water balance and uterine contractions, but not thyroid enlargement.
Choice C rationale:
The adrenal glands are responsible for producing hormones like cortisol and adrenaline. While adrenal disorders can lead to various hormonal imbalances, a goiter is not related to adrenal gland function. Adrenal issues might cause symptoms like fatigue, weight changes, and blood pressure irregularities.
Choice D rationale:
The anterior pituitary gland produces hormones that regulate the functions of other endocrine glands, including the thyroid gland. However, a goiter is not directly associated with the anterior pituitary. The anterior pituitary's malfunction can result in disorders like growth hormone deficiency or Cushing's disease, but not thyroid enlargement.
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