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 D

Explanation

Choice A rationale

Removing elbow restraints while the infant is sleeping is not a recommended intervention following cleft palate repair. Elbow restraints are used to prevent the infant from touching the surgical site and potentially causing injury or infection. Therefore, they should not be removed while the infant is sleeping.

Choice B rationale

Keeping the infant in a side-lying position is not a specific recommended intervention following cleft palate repair. The position of the infant following surgery will depend on various factors, including the infant’s comfort and the surgeon’s instructions.

Choice C rationale

Feeding the infant half-strength formula for the first 48 hours is not a specific recommended intervention following cleft palate repair. The infant’s feeding regimen following surgery will depend on various factors, including the infant’s age, weight, and overall health, as well as the surgeon’s instructions.

Choice D rationale

Administering pain medication PRN (as needed) for the first 48 hours is a recommended intervention following cleft palate repair. Pain management is an important part of postoperative care, and appropriate pain medication can help ensure the infant’s comfort and promote healing.

A. Lethargy. B. Respiratory rate 20/min. C. Lying flat on the unaffected side. D. Urine output 50 mL in 2 hr. .

Correct Answer is A

Explanation

Choice A rationale

Lethargy in a child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt could indicate a serious problem such as shunt malfunction or infection, and should be the priority.

Choice B rationale

A respiratory rate of 20/min is within the normal range for a 4-year-old child and is not typically a cause for concern.

Choice C rationale

Lying flat on the unaffected side is not typically a cause for concern following ventriculoperitoneal shunt surgery.

Choice D rationale

A urine output of 50 mL in 2 hr is within the normal range for a 4-year-old child and is not typically a cause for concern.

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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 contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair.Which of the following interventions should the nurse contribute to the client’s plan of care?

Correct Answer is D

Explanation

A nurse is caring for a 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt.Which of the following findings should the nurse identify as the priority?

Correct Answer is A

Explanation

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