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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Correct Answer is C
Explanation
Choice A reason: Providing frequent range of motion to the neck and shoulders is not recommended for an infant with bacterial meningitis, as it could cause discomfort or pain due to the inflammation of the meninges.
Choice B reason: Keeping the television on to provide background noise is not advisable, as infants with meningitis may be sensitive to noise, and it could potentially increase their discomfort or agitation.
Choice C reason: Padding the siderails of the crib is important to ensure the safety of the infant. It helps to prevent injury if the infant has seizures, which can be a complication of meningitis.
Choice D reason: Placing the infant in a semi-private room is not a specific intervention for the care of an infant with bacterial meningitis. It is more important to focus on interventions that address the infant's immediate health needs.
Correct Answer is A
Explanation
Choice A reason: Hyperpyrexia, or extremely high fever, is a common symptom of acetylsalicylic acid (aspirin) poisoning. The body's response to the toxic levels of aspirin can lead to an elevated temperature as part of a systemic inflammatory response.
Choice B reason: Jaundice is not a typical symptom of acute acetylsalicylic acid poisoning. It is more commonly associated with liver conditions that cause an increase in bilirubin levels.
Choice C reason: Neck vein distention is not a common finding in acetylsalicylic acid poisoning. It is often seen in conditions that cause increased pressure in the venous system, such as heart failure.
Choice D reason: Polyuria, or excessive urination, is not a direct symptom of acetylsalicylic acid poisoning. While changes in urination can occur due to renal involvement, hyperpyrexia is a more immediate concern.
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