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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Hypertension is not a typical finding in severe dehydration. In fact, dehydration often leads to decreased blood pressure.

B. Increased urine output is not a typical finding in severe dehydration. Dehydration leads to decreased urine output as the body tries to conserve fluids.

C. This is the correct answer. In severe dehydration, the body compensates by increasing the respiratory rate to try to maintain oxygen levels and remove excess carbon dioxide. This is a compensatory mechanism in response to metabolic acidosis, which can occur with dehydration.

D. A capillary refill of 2 seconds indicates normal perfusion. In severe dehydration, capillary refill may be prolonged, indicating poor perfusion.

A. Increased restlessness B. Respiratory rate 25/min C. Bowel sounds 20/min D. Urinary output 35 mL/hr

Correct Answer is A

Explanation

A. Increased restlessness can indicate hypoxia, pain, or worsening shock, which are critical concerns in a toddler with significant burns. This finding should be reported immediately.
B. Respiratory rate of 25/min is within the normal range for a toddler (22-37 breaths per minute) and does not require immediate intervention.
C. Bowel sounds of 20/min are normal and do not indicate a complication.
D. Urinary output of 35 mL/hr is adequate for a toddler (goal: ≥1-2 mL/kg/hr, which would be ≥20-40 mL/hr for a 20 kg child) and does not require reporting.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning to perform tracheostomy care for a toddler. Which of the following is an appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an infant who has severe dehydration due to gastroenteritis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full-thickness burn to 10% of his body. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is planning care for an adolescent who has sickle cell anemia which of the following immunizations should the nurse include in the plan?

A nurse is teaching a parent about home interventions for a preschooler who is experiencing night terrors. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a school-age child who is 1 hr postoperative following a tonsillectomy. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?

A charge nurse is teaching a group of nurses about identifying child abuse. Which of the following findings should the nurse identify as a potential indicator of child abuse?

A nurse is evaluating a 4-year-old child who has cystic fibrosis and has been receiving chest physiotherapy treatments. The nurse should identify which of the following findings is an indication that the therapy has been effective.

A nurse is planning to admit a preschooler from the PACU following the removal of a Wilms tumor. Which of the following children should the nurse identify as an appropriate roommate for the preschooler?

A nurse is planning to teach an adolescent who is lactose intolerant about dietary guidelines. Which of the following instructions should the nurse include in the teaching?