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 C
Explanation
The correct answer is choice C. Activity intolerance related to generalized weakness.
Choice A rationale:
Risk for injury related to depressed sensorium. This choice is not the most appropriate nursing diagnosis for a child with moderate anemia. While anemia can lead to fatigue and weakness, the main concern is the child's ability to tolerate physical activities, not the risk of injury due to a depressed sensorium.
Choice B rationale:
Decreased cardiac output related to abnormal hemoglobin. This choice is not the most suitable nursing diagnosis for a child with moderate anemia. While abnormal hemoglobin levels can affect cardiac output, moderate anemia typically doesn't lead to such a significant decrease in cardiac output that it becomes the primary nursing diagnosis. Activity intolerance is a more relevant concern.
Choice C rationale:
Activity intolerance related to generalized weakness. This is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia. Moderate anemia results in a decrease in oxygen-carrying capacity, leading to generalized weakness and reduced ability to perform physical activities without becoming fatigued. The child's hemoglobin levels are likely low enough to cause noticeable activity intolerance.
Choice D rationale:
Risk for Injury related to dehydration and abnormal hemoglobin. This choice is not the best nursing diagnosis for a child with moderate anemia. Dehydration may exacerbate the effects of anemia, but the primary issue here is the anemia itself causing weakness and activity intolerance, which are better addressed with the choice C diagnosis.
Correct Answer is C
Explanation
The correct answer is choice C. Sparse hair.
Choice A rationale:
Sleepiness is not a typical symptom of hypothyroidism. Hypothyroidism, a condition where the thyroid gland doesn't produce enough thyroid hormone, leads to a slower metabolism which can cause fatigue, but not necessarily sleepiness.
Choice B rationale:
Weight loss is not associated with hypothyroidism. In fact, weight gain is a common symptom due to the reduced metabolic rate caused by insufficient thyroid hormone levels.
Choice C rationale:
Sparse hair is a characteristic symptom of hypothyroidism. The thyroid hormones play a crucial role in the growth and maintenance of hair follicles. In hypothyroidism, hair can become brittle, thin, and sparse.
Choice D rationale:
Diarrhea is not a typical symptom of hypothyroidism. Constipation, on the other hand, is more commonly associated with this condition due to the slowed digestive processes caused by low thyroid hormone levels.
Choice E rationale:
Puffiness around the eyes is not typically associated with hypothyroidism. However, it is a symptom of another thyroid disorder known as Graves' disease, which is characterized by hyperthyroidism (overactive thyroid).
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