A nurse is caring for a child who has a tracheostomy.
After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?
Stable oxygen saturation.
Clear breath sounds.
Brisk capillary refill.
Increased respiratory rate.
The Correct Answer is B
Choice A rationale
Stable oxygen saturation indicates effective gas exchange but does not directly confirm patency of the airway or removal of secretions. While improved oxygenation is a goal, the primary determinant of effective tracheostomy suctioning is the clearing of mucus from the tracheobronchial tree, which would then lead to improved air movement and clear lung sounds.
Choice B rationale
Clear breath sounds are the most direct and reliable indicator of effective tracheostomy suctioning. The presence of adventitious breath sounds, such as rhonchi or crackles, suggests retained secretions. Successful removal of these secretions through suctioning allows for unimpeded airflow, resulting in the auscultation of clear, vesicular breath sounds over the lung fields.
Choice C rationale
Brisk capillary refill indicates adequate peripheral perfusion and cardiac output but does not directly assess the patency of the airway or the effectiveness of tracheostomy suctioning. While a child with respiratory compromise might have delayed capillary refill, its improvement is a systemic sign of improved oxygenation, not a specific measure of airway clearance.
Choice D rationale
An increased respiratory rate after suctioning could indicate persistent respiratory distress or even irritation from the procedure, rather than effectiveness. A decreased or normalized respiratory rate would be a more positive sign, indicating that the airway has been cleared and the work of breathing has lessened, allowing the child to breathe more comfortably and efficiently.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Maintaining a semi-Fowler's position promotes lung expansion by reducing abdominal pressure on the diaphragm, facilitating easier breathing. However, while it aids ventilation, it does not directly address the viscosity of tenacious secretions by increasing their fluidity, which is crucial for expectoration.
Choice B rationale
Encouraging daily fluid intake of 2 to 3 L helps to thin bronchial secretions by increasing the systemic hydration, thereby decreasing their viscosity. This liquefaction makes the mucus less tenacious and significantly easier for the client to mobilize and expectorate through coughing, improving airway clearance.
Choice C rationale
Administering oxygen via nasal cannula at 2 L/min provides supplemental oxygen to improve oxygen saturation but does not directly influence the consistency or mobility of bronchial secretions. While essential for hypoxemia, it doesn't address the underlying issue of tenacious mucus.
Choice D rationale
Helping the client select a low-salt diet is primarily relevant for managing fluid retention, hypertension, or cardiovascular conditions. It has no direct physiological effect on the viscosity or ease of expectoration of bronchial secretions in a client with COPD.
Correct Answer is A
Explanation
Choice A rationale
Slow, steady bubbling in the suction control chamber of a closed chest drainage system is an expected finding, indicating that the prescribed suction level is being appropriately applied to facilitate lung re-expansion and fluid removal. Continuing to monitor the client's respiratory status is the appropriate action to ensure optimal function and patient well-being.
Choice B rationale
Checking the tubing connections for leaks is indicated when there is continuous or excessive bubbling in the water-seal chamber, which suggests an air leak in the system. Slow, steady bubbling in the suction control chamber is normal and does not necessitate a leak check.
Choice C rationale
Checking the suction control outlet on the wall is necessary if there is no bubbling in the suction control chamber when suction is prescribed, indicating a lack of suction. Since bubbling is noted, the wall suction is likely functioning correctly.
Choice D rationale
Clamping the chest tube without a specific physician's order or immediate indication, such as accidental disconnection or tube change, is generally contraindicated. Clamping can lead to a tension pneumothorax by trapping air or fluid in the pleural space, which is a life-threatening complication.
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