A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

Use medical asepsis when performing the procedure.

Apply suction for 10 seconds.

Advance the catheter 2 cm (0.8 in) after resistance is met.

Withdraw the catheter if the client begins coughing.

Answer and Explanation

The Correct Answer is B

A. Surgical asepsis (sterile technique) should be used for suctioning to prevent infection, not medical asepsis.

B. Applying suction for no longer than 10 seconds is appropriate to prevent hypoxia and trauma to the airway.

C. Advancing the catheter 2 cm after resistance is met is not advised; the catheter should not be forced beyond resistance to avoid injury.

D. The catheter should not be withdrawn if the client begins coughing; instead, it indicates the need for suctioning. If coughing occurs, the nurse should ensure the patient can breathe and may need to suction carefully.

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Correct Answer is D

Explanation

A. Decreased heart rate is not typical; children with Kawasaki disease often experience tachycardia.

B. Peeling of the soles of the feet is more commonly observed in the convalescent phase of Kawasaki disease rather than the acute phase.

C. Pain in weight-bearing joints can occur in Kawasaki disease but is not the hallmark symptom during the acute phase.

D. Fever unresponsive to antipyretics is a classic finding in the acute phase of Kawasaki disease, indicating ongoing inflammation and a need for further intervention.

A. Prepare for an emergency cesarean birth. B. Assist the client to a knee-chest position. C. Prepare the client for continuous internal monitoring. D. Continue observing the fetal heart rate.

Correct Answer is D

Explanation

A. Early decelerations are typically benign and often associated with head compression, not necessitating an emergency cesarean birth.

B. A knee-chest position is generally used for variable decelerations but is not indicated for early decelerations.

C. Continuous internal monitoring may be necessary in certain situations, but in the case of early decelerations, it is not an immediate intervention.

D. Early decelerations usually require continued monitoring without immediate intervention as they typically resolve spontaneously with contractions.

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A nurse is performing tracheostomy care for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take when suctioning the client's airway?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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