A nurse is planning to perform tracheostomy care for a toddler.
which of the following is an appropriate action for nurse to take?
use clean technique to change the tracheostomy tube.
clean around the stoma with full -strength hydrogen peroxide.
Place the child in Trendelenburg position when performing care.
Have the child flex his head when securing the ties.
The Correct Answer is D
The correct answer is D. Have the child flex his head when securing the ties.
Explanation:
When securing tracheostomy ties, flexing the head helps ensure the ties are snug but not too tight. This minimizes the risk of accidental dislodgement while allowing proper airway support.
Why the other options are incorrect:
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A. Use clean technique to change the tracheostomy tube – Incorrect. Sterile technique is required when changing the tracheostomy tube to prevent infection, especially in pediatric clients.
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B. Clean around the stoma with full-strength hydrogen peroxide – Incorrect. Diluted hydrogen peroxide or saline is recommended to avoid tissue irritation. Full-strength hydrogen peroxide can damage delicate skin around the stoma.
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C. Place the child in Trendelenburg position when performing care – Incorrect. The Trendelenburg position (head down, feet up) is not used for tracheostomy care and can increase the risk of aspiration or breathing difficulties.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Applying a warm pack to the injection site prior to administration is not recommended as it does not effectively reduce pain during immunizations.
Choice B rationale
Asking the parent to leave the room during the injections is not recommended as it may increase the infant’s anxiety and distress.
Choice C rationale
Administering the injections in the deltoid muscle is not recommended for a 2-month-old infant. The recommended site for intramuscular administration of immunizations in children under 18 months of age is the vastus lateralis (anterolateral thigh)3.
Choice D rationale
Administering the injections while the infant is breastfeeding is recommended. Breastfeeding during immunizations has been shown to significantly reduce pain and distress in infants.
Correct Answer is D
Explanation
During early adolescence, children often experience mood swings. This is due to the hormonal changes that occur during this stage of development.
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