A nurse is planning to perform tracheostomy care for a toddler. Which of the following is an appropriate action for the nurse to take?
Place the child in Trendelenburg position when performing care.
Use clean technique to change the tracheostomy tube.
Have the child flex his head when securing the ties.
Clean around the stoma with full-strength hydrogen peroxide.
The Correct Answer is C
A. Placing the child in the Trendelenburg position is not necessary for tracheostomy care. In fact, this position is generally not recommended for routine tracheostomy care.
B. Sterile technique, not clean technique, should be used when changing the tracheostomy tube to reduce the risk of infection.
C. This is the correct action. Having the child flex his head can help prevent tension on the tracheostomy ties and ensure a secure and comfortable fit.
D. Full-strength hydrogen peroxide is too harsh and can cause irritation to the skin around the stoma. It is recommended to use normal saline or a mild soap and water solution for cleaning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Oliguria (decreased urine output) is not typically associated with hypokalemia. It can be a symptom of other electrolyte imbalances or kidney dysfunction.
B. Hypertension (high blood pressure) is not a typical finding in a child with hypokalemia. Low potassium levels are more likely to be associated with cardiac dysrhythmias and hypotension.
C. Hyperactive bowel sounds are not directly related to hypokalemia. They can occur in various gastrointestinal conditions, but they are not a specific indicator of potassium
levels.
D. This is the correct answer. Hypokalemia (low potassium levels) can lead to decreased neuromuscular excitability, which can result in hyporeflexia (reduced reflexes). This is an important neurological sign associated with low potassium levels.
Correct Answer is C
Explanation
A. Placing the child in the Trendelenburg position is not necessary for tracheostomy care. In fact, this position is generally not recommended for routine tracheostomy care.
B. Sterile technique, not clean technique, should be used when changing the tracheostomy tube to reduce the risk of infection.
C. This is the correct action. Having the child flex his head can help prevent tension on the tracheostomy ties and ensure a secure and comfortable fit.
D. Full-strength hydrogen peroxide is too harsh and can cause irritation to the skin around the stoma. It is recommended to use normal saline or a mild soap and water solution for cleaning.
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