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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Report of diplopia
Diplopia, or double vision, can be a symptom of increased intracranial pressure (ICP) due to its effects on cranial nerve function. Therefore, it is a manifestation that the nurse should recognize as indicating the presence of increased ICP.
B. Hyperactivity
Hyperactivity is not typically associated with increased ICP. Instead, manifestations of increased ICP often include altered level of consciousness, lethargy, or even coma.
C. Nuchal rigidity
Nuchal rigidity, or stiffness in the neck, is not a direct manifestation of increased ICP. It is more commonly associated with meningitis or other conditions affecting the meninges.
D. Report of sore throat
A sore throat is not typically associated with increased ICP unless it is related to complications such as pharyngeal injury or infection.
Correct Answer is C
Explanation
A. "Gently put the tubes back into the child's ears": This is not the correct response. Tympanoplasty tubes are not meant to be reinserted if they fall out. Attempting to reinsert them without proper medical training could cause injury or damage to the child's ears. Therefore, this response should be avoided.
B. "Bring the child to the emergency department immediately": While it's important for the parent to seek medical attention if the tubes fall out, it may not always necessitate a visit to the emergency department, especially if the child is not experiencing any other symptoms. This response might cause unnecessary panic for the parent and may not be the most appropriate course of action.
C. "Notify the provider that the tubes have fallen out": This is the correct response. If the tympanoplasty tubes fall out, the parent should notify the healthcare provider who performed the procedure. The provider can then assess the situation and determine the next steps, which may include scheduling a follow-up appointment to evaluate the child's ears.
D. "The tubes are sutured in place and must be surgically removed": This is incorrect. Tympanoplasty tubes are not sutured in place; they are typically designed to fall out on their own after a certain period of time. Additionally, removal of tympanoplasty tubes usually does not require another surgical procedure.
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