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 D

Explanation

A. Decreased respiratory rate: AKI typically does not directly affect respiratory rate. Respiratory rate is more closely related to lung function and oxygenation status rather than kidney function.

B. Polyuria: This is an incorrect option. Polyuria, or increased urine output, is not typically seen in acute kidney injury. In fact, oliguria (decreased urine output) or anuria (absence of urine output) are more common in AKI due to decreased kidney function.

C. Hyperactivity: AKI does not typically cause hyperactivity. In fact, children with AKI may appear lethargic or fatigued due to the buildup of waste products in their bodies and electrolyte imbalances.

D. Edema: This is the correct option. Edema, or swelling due to fluid retention, is a common clinical manifestation of AKI. When the kidneys are unable to adequately filter and excrete excess fluid from the body, fluid accumulates in the tissues, leading to edema. Edema may be particularly noticeable in the face, hands, feet, or around the eyes.

A. New heart murmur B. Weight gain C. Bradycardia D. Decreased body temperature

Correct Answer is A

Explanation

A. New heart murmur

This is a common finding in infective endocarditis due to damage to the heart valves caused by the infection. The infection can lead to the development of new heart murmurs or changes in existing ones as the valves become affected.

B. Weight gain

Weight gain is not typically associated with infective endocarditis. In fact, individuals with infective endocarditis may experience weight loss due to symptoms such as fever, loss of appetite, and malaise.

C. Bradycardia

Bradycardia, or a slow heart rate, is not a typical finding in infective endocarditis. In many cases, individuals with infective endocarditis may actually present with tachycardia (rapid heart rate) due to fever and the body's response to infection.

D. Decreased body temperature

Infective endocarditis is often associated with fever, which would lead to an elevated body temperature rather than a decreased one.

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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

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