A nurse is completing an assessment following suctioning of a child who has a tracheostomy. Which of the following findings should the nurse identify as an indication that the procedure has been effective?

Increased respiratory rate

Decreased oxygen saturation

Clear breath sounds

Increased oral secretions

Answer and Explanation

The Correct Answer is C

A. Increased respiratory rate: An increased respiratory rate may indicate that the child is experiencing respiratory distress or discomfort, which could be a sign that suctioning was not effective or that it was too aggressive. Ideally, after suctioning, the child's respiratory rate should stabilize or decrease as they are able to breathe more comfortably with a clear airway.

B. Decreased oxygen saturation: A decreased oxygen saturation level may indicate that the child is not receiving enough oxygen, which could be a sign of ineffective suctioning or airway obstruction. Effective suctioning should improve oxygenation by removing secretions and allowing for better airflow. A decrease in oxygen saturation would suggest the need for further assessment and intervention.

C. Clear breath sounds: This is the correct option. Clear breath sounds indicate that the airway has been effectively cleared of excess secretions, allowing for clear airflow. After suctioning, the nurse should listen for clear breath sounds without any crackles, wheezes, or other abnormal sounds indicating obstruction or congestion.

D. Increased oral secretions: Increased oral secretions may suggest that suctioning was not effective in clearing secretions from the airway, leading to pooling of secretions in the mouth. Effective suctioning should remove excess secretions from the airway, reducing the need for excessive oral secretions.

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Correct Answer is C

Explanation

A. Have the child perform passive range-of-motion exercises: This is not recommended during acute hemarthrosis in hemophilia because it can further exacerbate bleeding and increase joint damage. Passive range-of-motion exercises should be avoided until bleeding has been adequately controlled.

B. Administer aspirin as needed for pain: Aspirin is not recommended for pain management in hemophilia due to its antiplatelet effects, which can further prolong bleeding. Instead, acetaminophen (Tylenol) or other nonsteroidal anti-inflammatory drugs (NSAIDs) that do not affect clotting mechanisms may be used for pain relief.

C. Place ice packs on the affected joints: This is a recommended intervention. Ice packs can help reduce inflammation and swelling in the affected joints, providing pain relief and potentially slowing down bleeding. However, it's important to ensure that the ice pack is wrapped in a cloth or towel to prevent direct contact with the skin, which could cause tissue damage.

D. Position the lower extremities below the level of the heart: This is not recommended. Elevating the affected extremity above the level of the heart can help reduce swelling and minimize bleeding. Placing the lower extremities below the level of the heart could potentially increase bleeding.

A. Give the infant liquids using a small spoon with a long handle. B. Apply elbow restraints to the infant. C. Gently check the infant's suture line using a padded tongue depressor. D. Place the infant in a supine position.

Correct Answer is B

Explanation

A. Give the infant liquids using a small spoon with a long handle.

Give the infant liquids using a small spoon with a long handle.While feeding is essential, the method described is not specific to postoperative care after cleft palate repair.Feedings are resumed by bottle, breast/chest, or cup per surgeon preference; some surgeons prescribe the use of an Asepto syringe for feeding or a soft cup such as a soft-tipped sippy cup.

B. Apply elbow restraints to the infant.

Apply elbow restraints to the infant is correct.Elbow restraints would be used to prevent the infant from injuring or traumatizing the surgical site.

C. Gently check the infant's suture line using a padded tongue depressor.

It's important to assess the surgical site for signs of infection or bleeding, but using a padded tongue depressor may not be the most appropriate method. The nurse should follow the surgeon's orders regarding wound care and assessment techniques, which may include visual inspection without manipulation.

D. Place the infant in a supine position.

Placing the infant in a supine position is generally recommended after cleft palate repair surgery to minimize strain on the surgical site and promote healing. However, it's essential to ensure proper positioning to prevent aspiration and maintain airway patency.

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A nurse is completing an assessment following suctioning of a child who has a tracheostomy. Which of the following findings should the nurse identify as an indication that the procedure has been effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a 4-year-old child who has hemophilia and is experiencing acute hemarthrosis. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is caring for a 4-month-old infant who is immediately postoperative following cleft palate repair. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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