When suctioning a child with a tracheostomy, what should the nurse do to maintain a patent airway and prevent complications?

Apply suction continuously while inserting the suction catheter.

Use a large diameter suction catheter for better suctioning.

Suction for no more than 10 seconds at a time.

Apply suction while the child is exhaling.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Applying suction continuously while inserting the suction catheter is not recommended. This could potentially cause trauma to the trachea and lead to complications.

Choice B rationale

Using a large diameter suction catheter for better suctioning is not recommended. The size of the suction catheter should be appropriate for the size of the tracheostomy tube. Using a catheter that is too large could cause trauma to the trachea.

Choice C rationale

Suctioning for no more than 10 seconds at a time is recommended to prevent hypoxia (lack of oxygen). Prolonged suctioning can lead to complications such as hypoxia, trauma to the trachea, and cardiac arrhythmias.

Choice D rationale

Applying suction while the child is exhaling is not recommended. Suction should be applied while withdrawing the suction catheter, not during exhalation.

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Correct Answer is B

Explanation

Choice A rationale

A set of blocks to build a block tower may not be suitable for a 7-month-old infant. At this age, infants are still developing their fine motor skills and may not have the dexterity to stack blocks effectively. Moreover, there’s a risk of the infant putting small blocks in their mouth, posing a choking hazard.

Choice B rationale

A soft toy that squeaks or crackles when squeezed is an excellent choice for a 7-month-old infant. At this age, infants are exploring their environment through touch and sound. A soft toy that makes noise when squeezed can provide sensory stimulation and help develop their grasp reflex.

Choice C rationale

A colorful rib mobile that plays music might be more suitable for younger infants. By 7 months, infants are often able to sit up and may not spend as much time lying down looking at a mobile. Additionally, they may try to pull on the mobile, posing a safety risk.

Choice D rationale

A wooden farm animal puzzle with large pieces is typically more appropriate for older toddlers who have more advanced fine motor skills and cognitive abilities. A 7-month-old infant may not have the ability to understand the concept of a puzzle.

A. Notify the charge nurse of possible malabsorption. B. Check bowel sounds. C. Record retention of feeding. D. Elevate the child’s head.

Correct Answer is A

Explanation

Choice A rationale

An increasing abdominal girth in a child with a VP shunt may be indicative of malabsorption of the cerebrospinal fluid (CSF) that is being shunted to the peritoneum. This is because the VP shunt is a soft, flexible tube which is inserted into a lateral ventricle and acts as a drainpipe, to give the CSF a way to flow out of the ventricles. The tube is connected to a valve, which regulates the flow of CSF. The end of the shunt is placed within the abdominal cavity (tummy area), where the CSF will be reabsorbed. Therefore, if the CSF is not being properly absorbed in the peritoneum, it could lead to an increase in abdominal girth. This is a serious concern that needs immediate attention, hence the charge nurse should be notified.

Choice B rationale

Checking bowel sounds is a common nursing intervention for assessing gastrointestinal function. However, in the context of a child with a VP shunt and increasing abdominal girth, it is less likely to be directly related to the issue at hand. While bowel sounds can provide information about the functioning of the digestive system, they do not provide direct information about the functioning of the VP shunt or the absorption of CSF in the peritoneum.

Choice C rationale

Recording retention of feeding could be relevant in cases where there are concerns about the child’s nutritional status or digestive function. However, in this case, the primary concern is related to the functioning of the VP shunt and the absorption of CSF in the peritoneum. Therefore, while it’s always important to monitor feeding in a child, it is not the most appropriate response in this specific situation.

Choice D rationale

Elevating the child’s head is often done to reduce intracranial pressure, especially in patients with conditions affecting the brain or spinal cord. However, in the context of a child with a VP shunt and increasing abdominal girth, elevating the head would not address the underlying issue of potential malabsorption of CSF in the peritoneum.

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When suctioning a child with a tracheostomy, what should the nurse do to maintain a patent airway and prevent complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is selecting a toy for a 7-month-old infant.Which of the following toys should the nurse choose?

Correct Answer is B

Explanation

The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and observes an increasing abdominal girth.What is the most appropriate response?

Correct Answer is A

Explanation

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