A nurse is planning care for an 8-month-old infant with a tracheostomy. Which of the following actions should the nurse include in the plan of care?
Use a bulb syringe to suction the nares.
Provide antibiotic therapy.
Administer intermittent suction via the tracheostomy.
Place the infant in a prone position to sleep.
The Correct Answer is C
Choice A reason: Using a bulb syringe to suction the nares is a common practice for clearing nasal passages in infants, but it is not the primary concern for an infant with a tracheostomy, which requires specific care to maintain airway patency.
Choice B reason: Providing antibiotic therapy may be necessary if there is an infection, but it is not a standard care action for a tracheostomy without evidence of infection.
Choice C reason: Administering intermittent suction via the tracheostomy is essential to clear secretions and maintain airway patency, which is the greatest risk for an infant with a tracheostomy.
Choice D reason: Placing an infant in a prone position to sleep is not recommended due to the increased risk of sudden infant death syndrome (SIDS). Infants should be placed on their backs to sleep.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A reason: Rhinorrhea, or a runny nose, is a common symptom of RSV and, while it should be monitored, it is not typically an urgent concern that requires immediate reporting to a provider.
Choice B reason: Pharyngitis, or a sore throat, is another symptom that can be associated with RSV. Like rhinorrhea, it should be monitored but does not usually necessitate immediate reporting.
Choice C reason: Coughing is a typical symptom of RSV and is expected. It should be monitored for changes in character or severity but is not generally an urgent concern for immediate reporting.
Choice D reason: Tachypnea, or rapid breathing, is a sign of respiratory distress and is a critical finding in an infant with RSV. It indicates that the infant's ability to breathe effectively is compromised and requires immediate attention from a healthcare provider.
Correct Answer is C
Explanation
Choice A reason: Avoiding the removal of the cream prior to the procedure is important, but it does not specify when or how the cream should be applied, which is crucial for its effectiveness.
Choice B reason: Rubbing the cream into the skin is not recommended as it should be applied as a thick layer and covered with an occlusive dressing to ensure proper absorption and numbing effect.
Choice C reason: Applying the cream 1 hour before the procedure allows enough time for the lidocaine and prilocaine to take effect, providing adequate local anesthesia for the insertion of the IV catheter.
Choice D reason: Washing the site with alcohol prior to applying the cream is necessary to clean the area, but it is not the action that addresses the primary goal of numbing the site for the procedure.
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